PLEASE PRINT AND
PROVIDE TRUTHFUL AND ACCURATE RESPONSES TO EACH QUESTION
*
LEGAL NAME: ______________________________________________________________________
OTHER NAMES USED: _______________________________________________________________
*
DATE
OF BIRTH: ________________________
*
SSN:
__________________________________
PLACE OF BIRTH: ______________________________________
SEX: ___________________
*
CURRENT
ADDRESS: _____________________________________________________________________
_______________________________________________________________________________________
CITY: _____________________________________
STATE: ______________________________________
COUNTRY: ___________________________________________
ZIP CODE: _________________________
TELEPHONE NUMBERS:
(Residence) ________________________ (Business) _______________________
FACSIMILE: __________________________
E-MAIL: __________________________________________
PAGER: _________________________________
PLACE OF EMPLOYMENT: _________________________________________________________________
ADDRESS: ____________________________________
CITY ______________________________________
STATE: _______________________________
ZIP CODE _________________________________________
OCCUPATION: _____________________________________________________________________________________
MONTHLY INCOME/SALARY: __________________________________________
UNEMPLOYED ____ PRISONER
____ DISABLED____ STUDENT ____ RETIRED ____ MILITARY
____
[FURTHER EXPLANATION OF ABOVE
EMPLOYMENT STATUS
____________________________________________________________________________________
_____________________________________________________________________________________
EDUCATIONAL BACKGROUND:
(DEGREES/DIPLOMAS)
______________________________________________________________________________________
_____________________________________________________________________________
PROFESSIONAL LICENSES:
_____________________________________________________________________________
TRADES/SPECIAL SKILLS:
_________________________________________________________________________
CHECK ONE: COMMUNITY SUPPORTER
_____ FINANCIAL SUPPORTER _____ PRISON MEMBER ____
I HEREBY SUBMIT THIS
APPLICATION FOR COMMUNITY SUPPORTER/MEMBERSHIP INTO THE NEW PANTHER VANGUARD
MOVEMENT (NPVM). I WILL ABIDE BY ITS REASONABLE RULES OF CONDUCT AND ACTIVELY
PARTICIPATE IN ACTIVITIES TO CARRY OUT THE TEN POINT PLATFORM, OF THE NPVM,
WHICH I HEREBY AFFIRM MY SUPPORT, OR I WILL FINANCIALLY CONTRIBUTE MONTHLY
TO THE NPVM.
I ALSO HERBY FUTHER AFFIRM
THAT I AM NOT NOW EMPLOYED AS A LAW ENFORCEMENT AGENCY OF THE LOCAL, STATE
OR FEDERAL GOVERNMENT (UNLESS I HAVE DISCLOSED THIS FACT ABOVE) I FURTHER
AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE.
(WITHOUT A SOCIAL SECURITY
NUMBER, SIGNATURE AND DATE, THIS APPLICATION IS INVALID)
*
SIGNATURE:
_____________________________________________
*
DATED:
_________________________________________________
