(PLEASE PRINT AND MAIL BACK FOR REVIEW)
New Black Panther Party Memberships Application
Please complete entire application to ensure processing
Personal Information (please print)
Full Name: _______________________________________________________________________
Other Name: ___________________
Date of Birth: ___/___/_____
Address: _______________________________________________________________________
City: _______________ State/Providence: ____ Zip Code: _______
Phone: (____) ___________
Email Address:___________________________@_________________
Education Name and Address of School Circle Last Year Completed Did You Graduated Subjects Studied
| High School | 1 2 3 4 | Y N | ||
| College | 1 2 3 4 | Y N | ||
| Post College | 1 2 3 4 | Y N | ||
| Trade, Business, Other | 1 2 3 4 | Y N |
Organization Experience
Name Years Involved Duties Website
| National | 1 2 3 4 | |||
| Regional | 1 2 3 4 | |||
| Local | 1 2 3 4 | |||
| Other | 1 2 3 4 |
Specialized Skills/Training
| Have you ever served in the Military? Yes No |
If Yes what branch: _________________
Period of Service: ____ Date of Discharge: __/___/____
List specialized skills (i.e. Martial Arts, Electronics, Computer Tech, Medical, Communications) ____________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________Are you currently using any Medication? Yes No
If yes, please list the reason of usage: ____________________
_____________________________________
Have you ever been diagnosed with a mental condition: (please explain) ______________________________________
______________________________________
______________________________________
______________________________________Have you ever been convicted of a crime? __________________________________________
__________________________________________
Why are you interested in Joining the New Black Panther Party: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*Upon completion of your application, based on the discretion of the leadership you will be appointed an interview which will determine your eligibility for memberships*
I understand that by completing this application I may be required to sign a confidentiality agreement, should I become a member. I understand that completion of this application and any interview which may be granted does not ensure acceptance into the organization. I understand that all information given to the New Black Panther Party is confidential and will not be viewed by any outside personnel. I understand that if I am accepted for membership I am required to pay a $25.00 (non-refundable) new membership fee. I understand that if I am accepted, I agree to adhere to all the policies and procedure set-forth by the New Black Panther Party. Violation of these laws may result in the membership termination.
Date: ____/_____/__________ Signature: ________________________________
LA NBPP 