100 Black Men of Metropolitan St. Louis
2019 MEMBERSHIP APPLICATION

This is the application for consideration of induction into the 100 Black Men of Metropolitan St. Louis. Completion of this application is required along with the following information:

1) Identification of a Sponsor who is a current member of the 100 Black Men.
2) 2 (two) letters of recommendation
3) A copy of your CV or résumé
4) Payment of your application fee ($50)

Email address *
Contact Information
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City, State, Zip *
Your answer
Home Phone No. *
ex. 314-555-1212
Your answer
Cell Phone Number
ex. 314-555-1212
Your answer
Date of Birth (MM/DD/YYYY) *
MM
/
DD
/
YYYY
Sponsor Name *
(Must be a current 100 Black Men member)
Your answer
Marital Status *
Educational Background
Highest Level of Education Completed *
Currently Attending School? *
Undergraduate College/University (if applicable):
Your answer
Undergraduate Degree:
Your answer
Graduate College/University (if applicable):
Your answer
Graduate Degree:
Your answer
Special Certifications/Licences:
Your answer
Employment Information
Employer Name *
Your answer
Job Title *
Your answer
Work Phone Number
ex. 314-555-1212
Your answer
Professional Awards or Recognitions
Your answer
Community / Civic Involvement
Board Memberships
List any companies or organizations of which you sit on a Board of Directors, as well as your role with that organization.
Your answer
Organization Memberships
List any Professional, Social, Fraternal, or other organizations of which you are a member.
Your answer
Membership Interests
Interest in Organization *
Provide a brief summary of why you would like to be a member of the 100 Black Men of Metropolitan St. Louis
Your answer
Areas of Interest *
Tell us which areas you are interested in volunteering for with our organization.
Required
Special Skills and Qualifications
List any special skills and qualifications you have acquired from employment, previous work, or through other activities including hobbies or sports.
Your answer
Emergency Contact
Name *
Your answer
Phone No. *
ex. 314-555-1212
Your answer
Application Completion
Email recommendation letters and a copy of your CV or Résumé. *
Email an Adobe PDF or Microsoft Word copy of your letters of recommendation and curriculum vitae (CV) or résumé to info.100bmstl@gmail.com from the same email account provided above. The preference is to send them all as attachments to the same email.
Required
Application Fee *
There is a $50 non-refundable application fee, to cover the application processing and background check. Click on the link below to be taken to the PayPal site for payment. After payment is completed, enter the entire 17 digits of the PayPal Transaction ID from the receipt as verification of the payment. ....................................................................................................................................................................... https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=3QN9YW9LJ7R7E
Your answer
Application Consent *
By pressing "Submit Form", you understand consent to the following:
Acceptance Disclaimer *
By pressing "Submit Form", you understand and consent to the following:
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, sexual orientation, national origin, age, veteran or disability status. Thank you for completing this application form and for your interest.

100 Black Men of Metropolitan St. Louis, 4631 Delmar Blvd. St. Louis, MO 63108 (314) 367-7778 office, (314) 367-7771 fax, www.100blackmenstl.com.

A copy of your responses will be emailed to the address you provided.
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