Mentor Application | 100 Black Men of Tampa Bay

Your Details

Name *

First

Middle

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Employer Name *

Enter your current employer of business name.

Position Title *

How Long Employed *

Have you ever been convicted? *

Have you ever been convicted of a crime, other than any juvenile adjudication, which under the law which you were convicted was punishable by death or imprisonment in excess of 1 year, or that involved dishonesty or false statement regardless of the punishment? Note, a yes response does not automatically eliminate you from consideration for membership. If yes, please answer the next question.

If Yes convicted, please provide details

if yes, state as to each conviction the specific crime and the date and place of conviction

Will you submit to a background check? *

Yes
No

A background check will be conducted as part of the application process. Do you agree to submit your social security number and date of birth to complete the background investigation if needed? Background investigations are normally submitted by the applicant and a copy of the results provided to the Membership Chair by the Applicant. You will be contacted by the Membership Chair if this information is needed.

Are you currently a mentor for 100 Black Men or have you previously been one? *

Yes
No

List where you are/were a mentor.

Please include organization and chapter name(s).

Character References *

Please provide character references including name, address, phone number, and relationship.

Why do you want to be a mentor? *

Tell us why you would like to be a member of 100 Black Men of Tampa Bay, Inc.

Signature *

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Membership Application Form

Your Details