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Thank you in advance for becoming a member of CBPM
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The Collective Black People Movement (CBPM) Membership Application
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1. Name:
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Last
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Male
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Female
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Nickname
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First
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2. Mailing Address:
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street
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street number
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Apt #
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country
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city
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Zip Code
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state
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3. Phone Number
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Cell
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Home
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Business
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4. Email Address:
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Website Address:
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Place of Birth:
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5. Birthday:
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City/State/Country
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Month/Date/Year
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6. How did you hear about the Collective Black People Movement (CBPM)? Be specific.
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7. What special skills do you have that can benefit our people?
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8. Education: List your High School, Trade School, College, University, and/or Military experience below
along with the location, subject(s) studied, and years attended.
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Name of School
(H.S., Trade, college, Univ.)
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City & State
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Subject Studied
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Years
Attended
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1.
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2.
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3.
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4.
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9. Work Experience: List the areas of work that you are capable of doing for your people:
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B.
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C.
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A.
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10. Do you have a Business or Organization? If yes, list it (them) below, so that we can advertise your
business and organization to our people. Please send us a business card or a flyer...
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Name:
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Type:
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Website Address/Location:
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State:
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Phone #:
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City:
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1.
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2.
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3.
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Please give a one sentence mission on your Business or Organization in the space below:
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11. Type of Membership:
a. Check the type of membership you are interested in with the Collective Black People Movement.
b. Check how you would like to pay your membership (by the day, week, month, etc.)
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Day Week Month 3 Months 6 Months Year
Individual 27 Cents $1.89 $8.10 $24.30 $48.60 $97.20
Student 15 Cents $1.05 $4.50 $13.50 $27.00 $54.00
Elder 20 Cents $1.40 $6.00 $18.00 $36.00 $72.00
Family 75 Cents $5.75 $22.50 $67.50 $135.00 $270.00
Organization $1.00 $7.00 $30.00 $90.00 $180.00 $365.00
Business $1.00 $7.00 $30.00 $90.00 $180.00 $365.00
Church $1.00 $7.00 $30.00 $90.00 $180.00 $365.00
Honorary $1.00 $7.00 $30.00 $90.00 $180.00 $365.00
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If you signed up for a Family, Organization, or Church Membership, how many people is in your group?
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12. Check the Departments you would like to be involved with the Collective Black People Movement.
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Elder Council
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All Departments
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Physical Fitness
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Activist/Rallies/Letter Writing
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Employment
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Political
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Administration
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Engineering
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Promotions
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Arts & Crafts
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Farming/Produce
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Reggae
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Brothers Union
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Filming & Recording
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Reparations
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Business Operations
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Fundraising
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Repatriations
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Child Care
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Health & Nutrition
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Research
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Collective Record Company
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Hip-Hop
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Security
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History
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Computers
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Sisters Union
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Incarceration
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Construction
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Special Events
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Insurance
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Correspondence
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Spirituality
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Culture
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Law
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Sports
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Dance & Theatre
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Media
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Technology
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Dating/Relationship
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Medical
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United Front
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Documentation
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Membership
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Youths Union
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Education
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Operations/Management
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Other:
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13. Be Down with 10-10-50: Each person, of African Descent who would consider himself or herself
seriously concerned about the plight of African (Black) people and believe that: (Chech yes or no below)
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10 - Every black person should volunteer a minimum of ten (10) hours each month to a Black
Organization or Institution of their choice.
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10 - Every black person should contribute a minimum of $10 each month to help fund a Black
Organization of their choice.
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50 - Redirect a minimum of $50 each month from a Non-Black Business to a Black Business.
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I believe in the 10-10-50 system and I am Down with 10-10-50
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No
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Yes
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14. Check the other Black organizations that you are interested in hearing more about:
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All Black Organizations
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Million Man March Committee
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10-10-50 (African Community Center)
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Moorish Science of America
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100 Black Men
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NAACP
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Africa for the Africans
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Nation of Gods and Earths
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Nation of Islam
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African Union
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All-African People's Revolutionary Party (AAPRP)
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National Action Network
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National Christian Healthcare Network
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Ancient Egyptian Order
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New Black Panther Party
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Artist Collective
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New Order
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Black Male Community Empowerment Forum
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NCobra
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Black Women for Obama
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Nubian Nation
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Blackonomics
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Prison Outreach Ministry
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BOOM (Black Oppression Opposition Movement)
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Rainbow Push Coalition
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Coalition for Peoples’ Agenda
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Rastafari Community
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Concerned Dads Inc.
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Sankore African Study Circle
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Cultural Conscious Collective
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SCLC
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Dads on Duty
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Shake up the Plantation
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Ethiopian World Federation
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Sons and Daughters of Hariett Tubman
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Empress of Zion
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Sons of Children of Color (SOCOC)
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Equienox
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SOS Coalition of New Orleans Evacuees
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God's Children and Elders Think Tank
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Tag Team Network Marketing
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Gullah Inc.
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Uhuru Movement
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Hebrew Israelites
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UNIA - Universal Negro Improvement Ass.
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Keeping the Dream Alive
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Urban League
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Kwanzaa Association
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World African Diaspora Union (WADU)
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Life Skills Organization
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Other:
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Malcolm X Center for Self-Determination
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Men Stopping Violence
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Other:
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15. As a member of the Collective Black People Movement, I will be righteous in all dealings
with the members of the Collective Black People Movement and our people. (Please Chech Box)
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Today's Date:
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16. Membership was obtained by:
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Month/Date/Year
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