MEMBER APPLICATION Step 1 of 9 11% WHAT DOES MEMBERSHIP INCLUDE?"ImBlackInTech Membership Network" has 2 tiers of membership, Basic (free) and Premium (paid), that include: 1) Inclusion in our global membership network of founders and tech professionals2) Addition to the invitation list for ImBlackInTech events, across all nineteen (19) of our standard event series (pay per each individual event)3) An invitation to the ImBlackInTech slack channel 4) Access to the 2017 ImBlackInTech Resource List download ($50K+ worth of technology contract templates and trainings, investor and client presentation deck templates, the top paid pitch competitions nationwide, etc)5) FREE access to all ImBlackInTech standard events, across all 19 event series*6) Curated special offers, events and programs for paid members only (Investor dinners, 60 second pitch practice events, client presentation practice, etc)* excludes premium eventsUnanswered questions? List them here, and we will respond as we are able. Thank you. PERSONAL INFORMATIONName* First Last Email Address* Gender*ManWomanI identify as...GenderAge* COMPANY INFORMATIONCompany / Organization*What is the name of the company you run, or primarily work for / with?Title / Position*CategoryAgencyConsumer WebEnterprise WebEcommerceInvestorsMobileNon-Profit / CivicProfessional ServicesService CompanySoftwareOtherOther*Industry*Advertising / MarketingAutomotiveClean / Green TechConsumerDaily Deals / CouponsDeveloperEducationEmployment CenterEventsFashion / ApparelFeedback & AssessmentFinancialGamingHealth & FitnessHealthcareInvestorKids & FamilyLegalMeals & RestaurantsMusicNews & EntertainmentPaymentsProductivityReal EstateRetailSecuritySystem InnovationTechnologyTransportationTravelOtherOther*1-2 sentences detailing what your company does*1 sentence detailing what you do in your role* Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country WebsiteBlog BUSINESS INFORMATIONHow do you fit into the technology ecosystem? Check all that apply.* Tech Entrepreneur Tech Executive Tech Worker Tech Supporter With respect to your current company, are you a Starter or a Founder?* STARTER (Currently in idea phase, or in product development phase, but product is unfinished as of today) FOUNDER (Currently running startup, with a finished product, available for purchase today) TECH-ENABLED ENTREPRENEURS (Building a non-tech company. Tech Enabled = currently leveraging or seeking to learn how to leverage social media, apps and tech tools to grow their customer base online, and create more efficient systems internally to decrease the cost of doing business, increase efficiency, and increase revenue) PROFESSIONALS (Outside of the technology industry seeking to learn the strategies, tactics and step-by-step blueprint to start and/or grow a highly successful corporate career in technology) Tell us about your track record as an entrepreneur. Check all that apply.* FIRST-TIME ENTREPRENEUR (Currently running first startup) SEASONED ENTREPRENEUR (Founded 2 or more startups, currently running one) EXPERIENCE WITH EXIT (Founded at least one startup and executed a successful exit) GENERATING ROYALTY / RESIDUAL (You are still receiving payouts from a previous business that you no longer do work for/with) Revenue to Date*Tech EntrepreneurPre-Revenue: $0$1 – $9,999$10,000 – $49,999$50,000 – $99,999$100,000 – $499,999$500,000 – $999,999$1M – $10M> $10MHow much capital have you raised?Tech EntrepreneurBoot Strapped: $0$1 – $24,999$25,000 – $49,999$50,000 – $99,999$100,000 – $499,999$500,000 – $999,999$1M – $4.99M> $5MAre you currently raising capital?*Tech EntrepreneurNoYesHow much?Tech EntrepreneurWhat executive role do you perform in your company? If you perform multiple roles, check all boxes that apply.* FIRST-TIME EXECUTIVE (Currently running first startup, with a FINISHED product, available for purchase TODAY, as a C-Level Exec – CEO, COO, CTO, CIO, etc) SEASONED EXECUTIVE (Have run 2 or more startups, currently running one) EXPERIENCE WITH EXIT (Have run at least one startup and executed a successful exit) Revenue to Date*Tech ExecutivePre-Revenue: $0$1 – $9,999$10,000 – $49,999$50,000 – $99,999$100,000 – $499,999$500,000 – $999,999$1M – $10M> $10MIf you're running a startup, how much capital have you raised?Tech ExecutiveBoot Strapped: $0$1 – $24,999$25,000 – $49,999$50,000 – $99,999$100,000 – $499,999$500,000 – $999,999$1M – $4.99M> $5MAre you currently raising capital?*Tech ExecutiveNoYesHow much?Tech ExecutiveHow would you best describe your position in your company? If you perform multiple roles, check all boxes that apply.* Business Development Designer Developer Customer Service Marketing Other Please explain*How would you best describe how you fit into the "tech ecosystem" as a tech supporter? Check all boxes that apply.*Our SUPPORTERS have a kaleidoscope of different backgrounds, ethnicities, genders, capabilities, orientations, and experiences (Supporter = personal desire to see this global community of Black and Latinx founders and professionals grow, and contribute to it thriving) TECH ENTHUSIAST (General supporter and/or early adopter of apps and/or other tech related products and services) TECH INVESTOR (Angel, VC, etc) LEADER / MENTOR (Advisor, community manager, etc) CONSUMER (Frequent buyer of apps and or other tech related products and services) MEDIA (Employed by a publication in the tech space) JOURNALIST (Writer/content generator for a publication in the tech space) BLOGGER (Writer/content generator for your own blog in the tech space) STUDENT (Currently studying a technology related field, and or planning to pursue a career as a tech founder or tech worker) CATALYST (Event manager, deal broker, etc. You and or your company facilitate growth in the tech start-up ecosystem in some way) In what business stage do you typically focus your investment? Check all boxes that apply.* FRIENDS & FAMILY SEED (Angel & Super-Angel) SERIES A (Venture Capitalist) IN GENERAL, what's your sweet spot for investment dollar amount ranges?* < $50K < $100K $100K – $500K $500K – $1MM > $1MM How do you currently provide leadership and or guidance to tech startups?* Board Member for a tech startup, or multiple tech startups Official Advisor for a tech startup, or multiple tech startups Un-official Advisor for a tech startup, or multiple tech startups Founder or Leader of an organization or initiative focused primarily on people of color in technology BACKGROUNDHow did you hear about ImBlackInTech?* Word of Mouth Organization I participate with promoted ImBlackInTech Email list Read an article about ImBlackInTech Twitter LinkedIn Instagram Facebook Eventbrite NSBE Personally invited by Thomas K.R. Stovall Personally invited by Jason V. Stewart Other Please explain*What is your relationship to the person who shared ImBlackInTech with you? Friend Colleague Family Member Other Please explain*What is the name of the organization from which you heard about ImBlackInTech?From which email list did you hear about ImBlackInTech?In which publication, online or in print, did you see an article about ImBlackInTech?How did you hear about ImBlackInTech on Twitter? ImBlackInTech Twitter page A friend tweeted about ImBlackInTech and you saw it on their page Information about ImBlackInTech How did you hear about ImBlackInTech on LinkedIn? ImBlackInTech LinkedIn page A friend posted about ImBlackInTech and you saw it on their page Information about ImBlackInTech was shared with you directly from a friend How did you hear about ImBlackInTech on Instagram? ImBlackInTech Instagram page A friend posted about ImBlackInTech and you saw it on their page Information about ImBlackInTech was shared with you directly from a friend How did you hear about ImBlackInTech on Facebook? ImBlackInTech Facebook page A friend posted about ImBlackInTech and you saw it on their page Information about ImBlackInTech was shared with you directly from a friend What keywords were you searching for on Eventbrite when you happened upon ImBlackInTech?Please tell us how you heard about ImBlackInTech.*What are your preferred social networks? Instagram Twitter Facebook LinkedIn YouTube Snapchat Periscope Tumblr Pinterest If you would like for ImBlackInTech to tag you in Instagram images of you, and/or of images of events you attended, please input your preferred Instagram handleIf you would like for ImBlackInTech to tag you in Twitter images of you, and/or of images of events you attended, please input your preferred Twitter handleIf you would like for ImBlackInTech to tag you in Facebook images of you, and/or of images of events you attended, please input your preferred Facebook handleIf you would like for ImBlackInTech to tag you in LinkedIn images of you, and/or of images of events you attended, please input your preferred LinkedIn handleIf you would like for ImBlackInTech to connect with you on Snapchat, please input your preferred Snapchat handleIf you would like to subscribe to the ImBlackInTech YouTube channel, please find it at https://www.youtube.com/channel/UCqL3MkjicK8ue6-ns1KBWCg/videos. Please input your YouTube channel if you have content you would like ImBlackInTech to consider sharing.If you would like to subscribe to the ImBlackInTech Periscope channel, please find it at http://www.Periscope.tv. Please input your Periscope channel if you have content you would like ImBlackInTech to consider sharing.If you would like for ImBlackInTech to connect with you on Tumblr, please input your preferred Tumblr handleIf you would like for ImBlackInTech to connect with you on Pinterest, please input your preferred Pinterest handle COLLABORATE WITH USDo you have specific skill sets or resources that you would like to make available to ImBlackInTech to support our mission? Please let us know how you would like to engage by checking all boxes that apply.* I Am Not Yet Willing To Commit To Offering Help To ImBlackInTech Cash Sponsor In-Kind Sponsor (Food & Beverage, Liquor, Swag bags, etc) Venue Partner Request To Be Considered As A Potential Panelist I Have A Referral For A Potential Panelist Event Team Volunteer (Marketing, Sponsorships, PR, Production, Graphic Design, Multi-Media, etc) I Have No Relevant Skill Sets That I Can Offer To Help The ImBlackInTech Mission At This Time Other Please explain*You indicated that you are interested in a cash sponsorship for an ImBlackInTech event or event series. What do you have in mind?*You indicated that you are interested in an in-kind sponsorship for an ImBlackInTech event or event series. What do you have in mind?*You indicated that you are interested in being a venue partner for an ImBlackInTech event or event series. What do you have in mind?*Tell us about your subject matter expertise.*Please leave us the contact details for the individual you want to recommend as a panelist for a future ImBlackInTech event, and why you believe that they are a fit.*What specific skill set and or experience do you have to offer as a volunteer for the ImBlackInTech team? In addition to completing this form, please email Info@ImBlackInTech.com to discuss further.*How would you like to support our mission to accelerate the growth of Black and Latinx Founders and Professionals in (tech)?*Where do you reside?* City State / Province / Region AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Are you interested in being affiliated with an official ImBlackInTech Leadership Council, and bringing an ImBlackInTech chapter to your city?YesNoHow will you support an ImBlackInTech chapter coming to your city?I'm interested in starting / leading an ImBlackInTech chapter in my cityI'm NOT interested in starting / leading an ImBlackInTech chapter in my city, but I am interested in supporting chapter growth if someone else starts / leads the chapterWho are the organizations and/or individuals providing the most impactful support for tech entrepreneurs and/or tech professionals of color in your city?Enter names and/or URLs of organizations below, if applicableAre there any additional organizations and/or individuals focused primarily on people of color in technology that ImBlackInTech should be connected to?Enter names and/or URLs of organizations below, if applicable CHOOSE YOUR EVENTSPlease select all ImBlackInTech events for which you would like to be added to the invitation list.* IGNITE | B2B MICRO-CONFERENCE: Half day conference with part 1 of the day centered around panels and trainings offering guidance for B2B focused emerging tech startups looking to sell to the enterprise and city/government agencies. 2nd half of the day pairs buyers at BigCos and city agencies with vetted B2B focused startups, to pitch for 90 day paid pilot contracts, not investment BLACK TECH FAMILY REUNION(TM): The Black Tech Family Reunion(TM) is our national member conference, held in Summer 2018. The reunion brings together ImBlackInTech family members from all over the country to connect, learn, and forge true relationships that they can take with them, and bring back to their cities to grow their businesses and/or their careers. We identify potential leadership council members in various member cities we have identified for potential official chapters THE FOUNDERS SERIES (4): Quarterly training event series, which delivers five (5) deep dive panels in the curriculum. Each TFS training is a 60 minute “behind the red curtain” talk from a panel of all-star black and latinx founders from all over the country THE CORPORATE SERIES presenting sponsor US Cellular (4): Step-by-step blueprint to create a path toward senior level and director level positions and pay TALENTMATCH 2.0: Curated job matching initiative for corporations looking to source talent for technology related roles, from engineers to business development and marketing, from a diverse pool of candidates MAKING SENSE OF DIGITAL CURRENCIES: Learn the basics about digital currency, why it's relevant & how it will impact our future MONTHLY MIXER SERIES (12): On the 3rd Tuesday of each month, ImBlackInTech members, potential members and friends come together to share cocktails and conversation) APPS WITHOUT CODE (12): Monthly meetup led by Patrick Anderson TWILIGHT FOUNDER'S BRUNCH: 20 founders break bread with each other in a relaxing and curated environment over a delicious prix-fixe menu, and discuss opportunities to collaborate, and grow our businesses, together NOLA NIGHTS: Nola Nights is a night of food and fun for ImBlackInTech members, led by local expert chef Joelle Brown. Joelle trains us first hand on how to prepare a delicious New Orleans inspired dish, and we cook what we eat, over good conversation and great drinks VISION BOARDING EVENT: As a community, ImBlackInTech members will convene to create their vision boards for their lives and their businesses to jumpstart 2018 GLOBAL MASTERMIND: The ImBlackInTech™ Global Mastermind is a 1 year program for eight (8) entrepreneurs who can apply from anywhere around the globe. In total, the mastermind includes structures that have participants assess and plan around what it will take to produce satisfaction and happiness in 24 unique areas of our lives, including business, personal finances, relationships (family, friends, business, significant other), health, and more RE-IMAGINED CITIES | CHICAGO 2.0 presenting sponsor Civix (3): Meet The Innovators Making Chicago A Smart City GROWTH THROUGH GAMIFICATION: Meet “The Sugar Gamer,” Keisha Howard ALL JOKES ASIDE: The Intersection Between Comedy & Entrepreneurship, led by Raymond Lambert Do you want the opportunity to pitch at a future ImBlackInTech event?YesNoWould you like to be considered for a feature on ImBlackInTech's social channels?*NoYesPlease upload a PROFESSIONAL high-res photo of yourself (No effects, no text overlay, etc.)*Minimum 1000 X 1000px (.jpg or .png) Drop files here or From your perspective, what is the greatest need for tech entrepreneurs of color in your city?Why are you applying for an ImBlackInTech membership?*Whether you are a Founder, Starter, Tech Executive, Tech Worker or Supporter, we are pleased that you desire to join the ImBlackInTech Membership Network, and contribute to the growth of a high impact membership community focused on Black and Latinx founders and professionals. What specifically about this group has you want to join our global membership body? MEMBERSHIP TYPEImBlackInTech Membership Network has 2 tiers of membership, Basic (free) and Premium (paid).ImBlackInTech has produced 30+ events over the last 24 months, and over 20 of the last year. Over 90% of the events in the ImBlackInTech portfolio are reserved for attendance by ImBlackInTech members only. Must be a Free or Paid member to receive event invitations and attend ImBlackInTech events.Basic Membership: $0/yrBasic membership includes the following perks:1) Inclusion in our global membership network of founders2) Addition to the invitation list * for ImBlackInTech events, across the 19 standard event series in our portfolio **(Pay per event fee for each event you attend, online or at the door)3) An invitation to the ImBlackInTech Slack channelPremium Membership: $400/yrPremium membership gives members access to the following additional perks and privileges:1) Access to the 2017 ImBlackInTech Resource List ($50K+ worth of technology contract templates and trainings, investor and client presentation deck templates, the top paid pitch competitions nationwide, etc)2) FREE access to ImBlackInTech events, across the 19 standard event series in our portfolio **3) Curated special offers, events and programs for paid members only (Investor dinners, 60 second pitch practice events, client presentation practice, etc)* Basic memberships guarantee an invitation, but do not include complimentary entry to ImBlackInTech events** Excludes premium events (ie- Twilight Founders Brunch, TalentMatch 2.0, etc)What type of membership are you applying for?*Paid memberships receive priority consideration within 48 hours. If accepted, membership dues must be paid before Premium Member access is given.Paid MembershipFree MembershipCAPTCHA ImBlackInTech.com