Membership Application
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Name:.............................................................(Last), :......................................(First):...................(M.I)

Title:.....................

Address:............................................................................................................................................

City:............................................................, State:.............................................Zip:.........................

Tel: ( )_________________________(Home) ; ( ) _____________________(Office)
Email Address:_______________________@_________________
Cell/Pager: ( ) _____________________________

Profession:.......................................................................................................................................

Area(s) of Expertise:.........................................................................................................................

State Of Origin In Nigeria*:..............................................................................................................
(* Voluntary- This is to help in planning the political education agenda)
______________________________________________________________________________

Why I want to join the Forum:
[ ] To help achieve the goals of the organization
[ ] To seek elective office and promote/implement the goals of the organization
[ ] To contribute my expertise:
Such as :...................................................................................................................................
My vision of Nigeria:

A Brief Bio(use the other side of form):

Signature:.................................................... Date of Application:.................................................

[ ]Application fee: US $50(Fifty Dollars) [ ]Annual Membership fee US $100
Payment method : [ ] Cheque/Check* [ ] Money Order
* Make payable to Nigeria Democratic Leadership Forum/NDLF

Date Received:.................................... Amount:......................... Recommendation: [ ] A [ ] R
Official Signature:.......................................................................
Completed form to be returned to: Membership Committee, NDLF, c/o Caa. P. O. Box 282. Teaneck. Nj 07666. USA