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                                                                Biafra Actualization Forum Membership Application Form

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
Next of Kin: Name 
        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