MEMBERSHIP FORM – Civic Life Care Initiative

MEMBERSHIP FORMS

Name *

First

Middle

Last

Nationality *

State of Origin *

Sex *

Marital Status *

Occupation *

Phone Number *

Email Address *

SECTION B

Name of Next of Kin *

First

Last

Address *

Nationality *

Phone Number *

Email Address *

SECTION C

Name *

First

Last

Phone Number *

Email Address *

Registration Fee

Price: $5,000.00

The Above Charge is In Naira. Account Number: 2046969460 Account Name: Civic Life Care lnitiative Bank: First Bank

Terms and Conditions *

I hereby abide by the rules and regulations guiding the principles conduct of Civic Life Care lnitiative provisionally to any kind of rate.