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Any and all information given must be true and exact. Any discrepancies or
false information will result in rejection of
application. All applicants are subject to a polygraph test.
I, ____________________________________ swear that I am of good morals, good reputation and of sound mind,
I am a believer in the Christian religion, a native born American citizen and a White Gentile, I further swear that I am
at least 18 years of age, I am not a convicted felon and I am not a
consument of illegal drugs.
1. Name:____________________________________________________ 2. Date of Birth:____________________
4. Phone include area code:____________________________ 5. Age:_______ 6. Height:_______ 7. Weight:_______
8. Color Hair:_______ 9. Marital status:__________ 10. Name & decent of spouse:____________________________
11. Place of employment:________________________________ 12. Occupation:_____________________________
13. Do you have a high school diploma or GED?__________ 14. College?___________________________________
15. Physical condition:__________ 16. Explain if you are handicapped:______________________________________
17. Military / Experience:___________________________________ 18. Are you registered to vote?_____________
19. Previous political activity:__________________________ 20. Have you ever been a member of the KKK?_______
21. Have you ever been Banished by the Ku Klux Klan?_______ 22. Any legal charges pending against you?_________
22. Explain if you do have legal charges pending against you:______________________________________________
23. Have you ever worked for a law enforcement agency?_______ 24. Are you still employed by that agency?________
25. If you have worked for a law enforcement agency, where & how long?___________________________________
26. Why do you want to become a Klansman?________________________________________________________
27. Through what means were you able to contact the KKK?_____________________________________________
A $35.OO DONATION MUST ACCOMPANY THIS APPLICATION TO BE PROCESSED.
DUES ARE 10.00 MONTHLY OR 100.00 ANNUALLY.
I HEREBY SWEAR UNDER OATH AND PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE TO THE
BEST OF MY KNOWLEDGE.
SIGNATURE:____________________________________________ APPROVED BY:_____________________
P.O. Box 171
Bruce, Ms 38915