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application form

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REGISTRATION

A

 

1. NAME  .............................................

               SURNAME                         FIRST 

 

OTHERS  ..............................................

2. NATIONALITY..........   PASSPORT NO ...........

3. MARITAL STATUS ..........   PHONENO..... ......

4. AGE ........POSTAL ADDRESS ....................

                                              .......................

                                              .........................

 

5. SEX   .......               6. OCCUPATION ..........

 7. COUNTRY OF DEPARTURE   ...............         8. E-MAIL..........

 

B

 

1.     If married, will you travel with your spouse?

 2.     If yes, state name and occupation of spouse

        (a) Name .........................................

                           Surname                first name

         (b)   Occupation .......................

         (c)    Age ......................

         (d)   Other Traveling dependents ...........

                                                               

 

C

 

1.  Do you have a particular presentation you

     will like to give at the campaign?..............

 

2.  If yes, state the topic..............................

 ..........................................................

3.  How long will you be joining the campaign?

     (i)  2 weeks                          (ii) 4 weeks 

  Cost :  us$2,000.00                      us$4,000    

 

4.    Do you have any physical deformality or illness?

 

5.     If yes, state nature of deformality or illness

        ..............................................

   6.     Which type of accommodation do you wish to be provided with? 1star, 2star, 3star or 4star accommodation. tick                                             7.If others state.........................

 

D

 

TERMS OF AGREEMENT

 

I agree to abide by the rules and  regulations of the Constitution of the Movement for Anti-Drug Abuse (MADA) and do all my best to help in her campaign against drug abuse and HIV/Aids.

     

                         

 

           

          

 

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