Biafra Actualization Forum Membership Application Form

                                                               Biafra Actualization Forum Membership Application Form

Please complete the following information for your membership of Biafra Actualization Forum

Surname (Last Name):
First Name:
Middle Name:
Maiden Name (For married women only: Full family name):
Date of Birth (MM/DD/YYYY):
Place of Birth:     Country of Birth:
Village:                  Province / Locality:
Application Fee ($20 / €20 or Equivalent) Enclosed? Yes
Choose Annual Membership Pledge Amount:
Current Place of Residence (City/Town/Village): ,
                        State / Province/ County):     Country:

Current Occupation
Contact Phone:         Mobile Phone
Email:
Next of Kin: Name
        Address:
        Mobile Phone:

"I certify that all information given here is correct to the best of my knowledge and I will be held responsible for any misleading information, and thus pledge to the Sovereign Independent Nation of Biafra; so help me God."

Signed: Dated (MM/DD/YYYY)

Are you completing this application for your own self? Yes   IF NO:
Your Full Name:
Your Relationship to the applicant:
Your Village:      Province / Locality:
Do you have a Biafra Actualization Forum Membership yourself? Yes     No