Registration Form - Ikukuoma Campaign

SECTION A: PERSONAL INFORMATION

1. Full Name:

2. Date of Birth:

3. Gender:

Male Female Other

4. Phone Number:

5. Email Address:

6. Residential Address:

SECTION B: COMMUNITY & POLITICAL INFORMATION

7. LGA:

Ward:

8. Polling Unit:

9. Occupation/Profession:

10. Are you a registered voter?

Yes No

11. PVC Number (Optional):

12. Support Group Name (If any):

SECTION C: MEMBERSHIP INTEREST

13. Why do you want to join Ikukuoma Campaign Organisation?

SECTION D: DECLARATION

I, , hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that joining the Ikukuoma Campaign Organisation means I support its vision, mission, and candidate(s) and I am willing to contribute to its success.

Signature:

Date:

IKUKUOMA CAMPAIGN ORGANISATION

SECTION A: PERSONAL INFORMATION

SECTION B: COMMUNITY & POLITICAL INFORMATION

SECTION C: MEMBERSHIP INTEREST

SECTION D: DECLARATION

FOR OFFICIAL USE ONLY

IKUKUOMA CAMPAIGN ORGANISATION

SECTION A: PERSONAL INFORMATION

SECTION B: COMMUNITY & POLITICAL INFORMATION

SECTION C: MEMBERSHIP INTEREST

SECTION D: DECLARATION

FOR OFFICIAL USE ONLY

Thank You for Joining!