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CHONGAHBDAH ASSOCIATION
Membership Registration Form
1
Personal Info
2
Contact Details
3
Membership
4
Education
5
Business
6
Identification
7
Registration
8
Next of Kin
9
Declaration
SECTION A: PERSONAL INFORMATION
First Name *
Last Name *
Email Address *
Phone Number *
Password *
Minimum 8 characters
Confirm Password *
Gender *
Male
Female
Date of Birth
Select Marital Status
Single
Married
Divorced
Widowed
Marital Status
Number of Children
Passport Photograph
Click to upload passport photo
SECTION B: CONTACT DETAILS
Residential Address *
Permanent Address
Additional Phone Number(s)
Alternative Email Address
SECTION C: MEMBERSHIP & EMPLOYMENT DETAILS
Category of Membership *
Select Category
Student
Applicant
Working Class
Government Worker
Business Person
Occupation / Institution / Employer / Place of Work
Year of Employment
Grade Level (For Government Workers Only)
Expected Year of Retirement
SECTION D: EDUCATIONAL INFORMATION (FOR CURRENT STUDENTS ONLY)
This section is required only if you selected "Student" as your membership category.
Name of Institution *
Course of Study *
Level
Expected Year of Graduation
Address of Institution
SECTION E: SELF-EMPLOYMENT INFORMATION (IF APPLICABLE)
This section is required only if you selected "Business Person" as your membership category.
Nature of Trade / Business *
Business Address
Is the Business Registered?
Yes
No
Can You Train Apprentices?
Yes
No
SECTION F: IDENTIFICATION & ORIGIN
National Identification Number (NIN)
Voter Identification Number (VIN)
State of Origin *
Local Government Area (LGA) *
Do You Have a State/LGA Indigene Certificate or Letter?
Yes
No
SECTION G: REGISTRATION DETAILS
Type of Registration *
Select Type
Fresh Registration
Renewal
Fresh Registration: ₦1,000
Chapter / Branch *
Date of Registration (for Renewal)
Receipt Number / Proof of Payment
Click to upload receipt or proof of payment
SECTION H: NEXT OF KIN INFORMATION
Full Name of Next of Kin *
Select Relationship
Father
Mother
Spouse
Son
Daughter
Brother
Sister
Uncle
Aunt
Cousin
Friend
Other
Relationship *
Next of Kin Phone Number *
Next of Kin Address *
SECTION I: DECLARATION
Declaration:
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Member's Full Name *
Date *
Signature
Click to upload signature
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