BLACKDEMS: Educate. Empower. Energize.

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)