Thank you in advance for becoming a member of CBPM
The Collective Black  People Movement (CBPM) Membership Application
1. Name:
Last
 Male
 Female
Nickname
First
2. Mailing Address:
street
street number
 Apt #
state or region
city
 country
 Zip Code
3.  Phone Number
Cell
 Home
Business
4. Email Address:
 Website Address:
Place of Birth:
5. Birthday:
City/State/Country
Month/Date/Year
6.  How did you hear about the Collective Black People Movement (CBPM)? Be specific.
7.  What special skills do you have that can benefit our people?
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.
Name of School
(H.S., Trade, college, Univ.)
 City & State
 Subject Studied
 Years
Attended
1.
2.
3.
4.
9.  Work Experience:  List the areas of work that you are capable of doing for your people:
B.
C.
A.
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...
Name:
Type:
 Website Address/Location:
 State:
 Phone #:
City:
1.
2.
3.
 Please give a one sentence mission on your Business or Organization in the space below:
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.)
                           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
If you signed up for a Family, Organization, or Church Membership, how many people is in your group?
12.  Check the Departments you would like to be involved with the Collective Black People Movement.
Elder Council
All Departments
Physical Fitness
Activist/Rallies/Letter Writing
Employment
Political
Administration
 Engineering
Promotions
Arts & Crafts
 Farming/Produce
Reggae
Brothers Union
 Filming & Recording
Reparations
Business Operations
 Fundraising
Repatriations
Child Care
 Health & Nutrition
Research
Collective Record Company
 Hip-Hop
Security
History
Computers
Sisters Union
Incarceration
Construction
Special Events
Insurance
Correspondence
Spirituality
Culture
Law
Sports
Dance & Theatre
Media
Technology
Dating/Relationship
Medical
United Front
Documentation
Membership
Youths Union
Education
Operations/Management
Other:
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)
10 -  Every black person should volunteer a minimum of ten (10) hours each month to a Black  
Organization or Institution of their choice.  
10 -  Every black person should contribute a minimum of $10 each month to help fund a Black
Organization of their choice.
50 - Redirect a minimum of $50 each month from a Non-Black Business to a Black Business.
I believe in the 10-10-50 system and I am Down with 10-10-50
No
Yes
14.  Check the other Black organizations that you are interested in hearing more about:
All Black Organizations
 Million Man March Committee
10-10-50 (African Community Center)
Moorish Science of America
100 Black Men
NAACP
Africa for the Africans
 Nation of Gods and Earths
Nation of Islam
African Union
All-African People's Revolutionary Party (AAPRP)
 National Action Network
National Christian Healthcare Network
Ancient Egyptian Order
New Black Panther Party
Artist Collective
New Order
Black Male Community Empowerment Forum
NCobra
Black Women for Obama
Nubian Nation
Blackonomics
Prison Outreach Ministry
BOOM (Black Oppression Opposition Movement)
Rainbow Push Coalition
Coalition for Peoples’ Agenda
Rastafari Community
Concerned Dads Inc.
Sankore African Study Circle
Cultural Conscious Collective
SCLC
Dads on Duty
Shake up the Plantation
Ethiopian World Federation
Sons and Daughters of Hariett Tubman
Empress of Zion
Sons of Children of Color (SOCOC)
Equienox
SOS Coalition of New Orleans Evacuees
God's Children and Elders Think Tank
Tag Team Network Marketing
Gullah Inc.
Uhuru Movement
Hebrew Israelites
UNIA - Universal Negro Improvement Ass.
Keeping the Dream Alive
Urban League
Kwanzaa Association
World African Diaspora Union (WADU)
Life Skills Organization
Other:
Malcolm X Center for Self-Determination
Men Stopping Violence
Other:
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)
Today's Date:
16. Membership was obtained by:
Month/Date/Year
If you have any problems in becoming a member online please call  (404) HIP-JAZZ.
If you have any problems in becoming a member online please call  (404) HIP-JAZZ.