Double Family Registration

Pamoja Kenya Double Family Registration Form
1. NEW MEMBER INFORMATION
New Pamoja Kenya Member Name*
First Name Middle Initial Last Name
Telephone Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
2. SPOUSE
Add your spouse on your application?*
First Name*
Last Name*
Telephone*
Email*
3. NEXT OF KIN (Must be different name from the spouse)
First Name*
Last Name*
Telephone*
Email*
4. PARENTS
Add your living parents on your application?*
PARENT'S NAMES (Click the PLUS + sign to add another parent)
First Name Middle Initial Last Name
5. CHILDREN
Add your child/children on your application?*
CHILDREN (Click the PLUS + sign to add multiple children)
First Name Middle Initial Last Name
6. SIBLINGS
Add your living sibling(s) on your application?*
SIBLINGS (Brothers and sisters) - Not step-brothers or sisters.
First Name Middle Initial Last Name
7. OTHER FAMILY REGISTRATION
Add in-laws or step-family on your application?*
Father In-law
First Name Middle Initial Last Name
Mother In-law
First Name Middle Initial Last Name
Brother/Sister In-laws
First Name Middle Initial Last Name
Step Mother
First Name Middle Initial Last Name
Step-Brothers/Sisters
First Name Middle Initial Last Name
8. DECLARATION
Consent*
I declare that:
by entering my name below and submitting my ID, I declare that the information provided on this form is accurate, true, and correct. I understand that any misrepresentation of material fact herein may render my membership null and void at the discretion of the Pamoja Kenya Board of Trustees. Upon registration, I agree to remain a Pamoja Kenya member for at least five (5) years after benefiting, failure to follow the signed agreement, Pamoja Kenya shall have a right to take a legal action against me to recover the total amount of any money given me.
New Member Name*
First Name Middle Initial Last Name
Your Official Government ID Number*
Upload | Front Image of your ID*
Accepted file types: jpg, Max. file size: 128 MB.
Signature*
Date*
9. REFERRED BY:
Referred by:*
First Name Last Name Telephone Number
9. PAY YOUR REGISTRATION FEES AND FIRST SHARES
New Double Family Membership Registration Fees ($ 400)*
Shares Payment for Double Family Membership (20 shares X $40.00 = $800)*
Fees for Processing your Payment (Sent to PayPal - $42.37)*
Total
$0.00
Payment Method*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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WHAT NEXT? If PayPal is Active....
Click PayPal below to PAY and SUBMIT your form to Pamoja Kenya Officials
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FOR OFFICE USE ONLY: Pamoja Kenya Reviewer
Please note: Pamoja Kenya Official must complete this section upon review of this application.
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Verified by (Name of Pamoja Kenya Official):
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Date
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Verified by (Name of Pamoja Kenya Official):
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Date

First Name	Middle Initial	Last Name

First Name	Middle Initial	Last Name

First Name	Middle Initial	Last Name

First Name	Middle Initial	Last Name

Double Family Registration

Pamoja Kenya Double Family Registration Form

1. NEW MEMBER INFORMATION

2. SPOUSE

3. NEXT OF KIN (Must be different name from the spouse)

4. PARENTS

5. CHILDREN

6. SIBLINGS

7. OTHER FAMILY REGISTRATION

8. DECLARATION

9. REFERRED BY:

9. PAY YOUR REGISTRATION FEES AND FIRST SHARES

WHAT NEXT? If PayPal is Active....

Click PayPal below to PAY and SUBMIT your form to Pamoja Kenya Officials

FOR OFFICE USE ONLY: Pamoja Kenya Reviewer