FOOD SOVEREIGNTY GHANA

 

 

 

APPLICATION FOR ASSOCIATE MEMBERSHIP REGISTRATION FORM

 

Please complete this form with the necessary accurate information. Registration fee is GH5.00.

1.(a) Surname:…………………………………………………………………….

 

(b) First Name:…………………………………………………………………….

 

(b) Other Names:…………………………………………………………………

(b) Date and Place of Birth:  ………./………../…………….  Place of Birth

(d) Residential Address:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

 

3. (a) Email Address: ………………………………@………………………………

(b) Mobile Phone No. s: ………………………………………

4. (a) Profession:	(b) District:
5.Current/Last Educational Institution Attended: Institution: ……………………………………………………………………………………………………………… Address: ……………………………………………………………………………………………………………… Period From: ……………/…………… To ………/…………./……
6. Tick any of the following and attach to this form; ID card: Drivers License NHIS Passport National Identification Date of Issue: ……..…/….……/………… Expiry Date: ………. /……………/…………… Day Month Year
7.Signature/Thumb Print: ……………………………………….. Membership Code: FSG/…../…../…………….		[photo]

 

 

I, (NAME) …………………………………………………………………………………………….. Certify that the above information is accurate and also declare to abide by the rules and regulations of FOOD SOVEREIGNTY GHANA.

 

Signature:………………………………………………………………….. Date: ………/……../……………