Questions marked with an asterisk (*) are mandatory.

	1. * Your First and Last Name

	2. * What is your date of birth (month and day only)?

	3. * What is your spouse's/significant other's date of birth (month and day only)?

	4. * What is your spouse's/significant other's name?

	5. * When is your employment anniversary (month and day only)?

	6. * In what year did you join the 100 Black Men of Madison?

	7. * Your Current, Complete Mailing Address