Membership Application Form

Black Autonomy Federation Membership Application

To apply for membership please complete all questions.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Facebook Page
Home Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Work Number

Area CodePhone Number
Best Way To Contact You (Email, Cell Phone, Etc.)
Check The Committee(s) You Would Like To Work On

Revolutionary Gang Truce/Youth EmpowermentBlack Poverty & Unemployment (Poor People’s Survival Committee)Police Brutality/Racial ProfilingBlack Autonomy Prison FederationForm A Black Autonomy Federation Chapter in My City (**Note: There is already an existing chapter in Memphis that local residents may join.)
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Black Autonomy Federation Membership Application