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 #
country
city
state
3.  Phone Number
Home
Cell
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)?
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?  If yes, list it (them) below, so that we can advertise your business to our
people.  Please send us a business card or a flyer..
Name:
Type:
 State:
 Phone #:
City:
Address/Location:
1.
2.
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             $2.00           $14.00        $60.00          $180.00           $360.00            $730.00

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
 Political
Employment
Administration
 Engineering
 Promotions
Arts & Crafts
 Farming/Produce
 Reparations
Brothers Union
 Filming & Recording
 Repatriations
Business Operations
 Fundraising
 Research
Child Care
 Health & Nutrition
 Security
Computers
Hip-Hop
 Sisters Union
Construction
History
 Special Events
Correspondence
 Incarceration
 Spirituality
Culture
 Law
 Sports
Dance & Theatre
 Media
 Technology
Dating/Relationship
 Medical
 United Front
Documentation
 Membership
 Youths Union
Education
Operations/Management
 Other:
13.  10-10-50/Problem Solvers United (PSU):  the Basic Plan for Empowerment of the African (black)
Community Worldwide.  Each person, of African Descent who would consider himself or herself seriously
concerned about the plight of African (Black) people must commit to the following: (Check each Box)
a.  Commit a minimum of ten (10) hours each month to a community based organization or
institution concerned with the uplift and improvement of our people.  
b.  Commit a minimum of $10 every month to help fund your chosen Black organization or  
institution.  Make a conscious effort to choose an organization or institution that needs your help.
c.  Transfer or redirect, at a minimum, an additional $50 from your monthly budget to support  
African (Black) owned businesses and their products and services.
14.  Check the other Black organizations that you are interested in hearing more about:
10-10-50 (African Community Center)
 The Children Think Tank
The National Christian Healthcare Network
 The New Black Panther Party
NAACP
 SCLC
Cultural Conscious Collective
 Nation of Islam
Nation of Gods and Earths
Atlanta Rastafari Community (ARC)
Urban League
Universal Negro Improvement Ass. (UNIA)
Ethiopian World Federation
The African American Male Initiative
Empress of Zion
 Rainbow Push Coalition
Artist Collective of Atlanta
Shake up the Plantation
Tag Team Network Marketing
NCobra
Hebrew Israelites
 Coalition for Peoples’ Agenda
Million Man March Committee
Kwanzaa Association
African Union
 National Action Network
Uhuru Movement
 The Nubian Nation
Malcolm X Center for Self-Determination
 BOOM (Black Oppression Opposition Movement)
Equienox
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.
Today's Date:
16. Membership was obtained by:
Month/Date/Year