Concerned Black Men of Richmond Adult Corp Application
Membership Application and Agreement
Please be sure to download paper app and submit to CBMRVA as well: http://www.cbmrichmondva.org/pdf/CBMAdultapplication.pdf
Email address *
Last Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone Number *
(xxx) xxx-xxxx
Your answer
Work Phone Number *
(xxx) xxx-xxxx
Your answer
Cellular Phone Number *
(xxx) xxx-xxxx
Your answer
Email Address *
Your answer
Hobbies: *
Your answer
Birthdate *
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DD
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YYYY
Name of Spouse/ Significant Other *
Your answer
Wedding Anniversary Date
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DD
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YYYY
Name and Age of Children *
Your answer
Why are you interested in joining CBM-R? *
Your answer
Signature *
Please Type Your Name As An Electronic Signature
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Today's Date *
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YYYY
Payment Information
(Checks for membership dues Payable to: Concerned Black Men of Richmond, Va., Inc. must be attached)
P. O. Box 4747
Richmond, VA 23220
(804) 343-2680
Membership Requirements
All potential new members must:

• Undergo a 90 day probationary period whereby you:

• Must participate in at least (3) youth activities.

• Will be assigned a mentor (from the current group of adult members) to help them understand the organization. This mentor may help with many items, but in particular, they will:

Serve as the first point of contact for questions about CBM-R.

Work with the new member during ALL one-on-one youth contact during the probationary period.


• Support the administrative workload of operating the organization:

Serve on at least one committee (within 30 days after completion of probationary period).

Work with other committees for major events as requested.


Complete a membership and a criminal background check application. All information contained in the criminal background check will be treated as confidential. Requests for exceptions to this policy must be made in writing and will be handled on a case-by-case basis by the Executive Board and the Support Council.


Any potential member with guilty convictions for the following offenses will be denied membership:

Sexual Offense/Abuse Felonies (Depending upon offense)
Child Abuse/Neglect Violent Crimes Against a Person (including Spousal Abuse)


MEMBERSHIP DUES

Annual membership dues $100.00 non-refundable, this fee is waived for full time college students. Payment of annual membership dues is due no later than October 31st of each year unless other arrangements have been made with the Treasurer for payment.

The Membership Committee and or Executive Board will review all membership actions/applications. The
Executive Board will then make the final decision.

All information supplied by me, is true to the best of my knowledge.

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