BLACKDEMS MEMBERSHIP APPLICATION
Applicant Information

Full Name: *required

Email Address::*required
Phone 1: Phone 2:
Fax::
Mailing Address: City
State: Zip:
   
Demographic Information
Date of Birth (dd/mm/yy) Sex Male Female

Occupation
Employer/Business Name
Race/Ethnicity
Marital Status
How Did You Hear About BLACKDEMS?
Referred/Invited by:
Blackdems.com/Internet Radio
Print Ad, Magazine, or Newspaper Television
Other, please specify
Committees/Areas of Interest
Public Relations Political Operations/Grassroots
Finance/Fundraising Expansion/New Chapter Development
Membership/Morale Special Projects
Policy/Legislative Research    
I have other specific areas of interestt, and I would like to speak with a BLACKDEMS officer about how I can contribute.
2 Friends I would Like to Tell About BLACKDEMS
Name Email Address Phone
Membership Level
After you hit "Submt" on this application you will be redirected to our contribution page. There you will be able to fufill payment of your membership dues via credit card, e-check, or pay pal.
Mortar - $25 Pilliar - $500
Brick - $200 Foundation - $1,000
In addition to my membership, I would like to make a donation in the amount of $
Signiture
I submit this form as request for membership in B L A C K D E M S. I understand that the credentials committee reserves the right to accept or deny any application for membershiop,a nd I wil be notified in the event that my application is denied. B L A C K D E M S does not determine membership eligiblity based on race, age, religion, sexual orientation or political affiliation.
Signiture of Applicant
   

Optional Personal Message:
 
Make a Financial Donation/Pay Membership Dues
 
Download Printable Membership Application (Word)