Pamoja Kenya Double Family Registration Form1. NEW MEMBER INFORMATIONNew 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 2. SPOUSEAdd your spouse on your application?*NoYesFirst Name*Last Name*Telephone*Email*3. NEXT OF KIN (Must be different name from the spouse)First Name*Last Name*Telephone*Email*4. PARENTSAdd your living parents on your application?*NoYesPARENT'S NAMES (Click the PLUS + sign to add another parent)First NameMiddle InitialLast Name 5. CHILDRENAdd your child/children on your application?*NoYesCHILDREN (Click the PLUS + sign to add multiple children)First NameMiddle InitialLast Name 6. SIBLINGSAdd your living sibling(s) on your application?*NoYesSIBLINGS (Brothers and sisters) - Not step-brothers or sisters.First NameMiddle InitialLast Name 7. OTHER FAMILY REGISTRATIONAdd in-laws or step-family on your application?*No, I do not wish to add in-laws or step familyin-lawsstep-familyFather In-law First Name Middle Initial Last Name Mother In-law First Name Middle Initial Last Name Brother/Sister In-lawsFirst NameMiddle InitialLast Name Step Mother First Name Middle Initial Last Name Step-Brothers/SistersFirst NameMiddle InitialLast Name 8. DECLARATIONConsent* 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.Signature*Date*9. REFERRED BY:Referred by:*First NameLast NameTelephone Number9. PAY YOUR REGISTRATION FEES AND FIRST SHARESNew Double Family Membership Registration Fees ($ 400)*Registration FeesShares Payment for Double Family Membership (10 shares X $40.00 = $ 400)*Shares Payment for Family Membership (10 shares X $40.00 = $ 400)Fees for Processing your Payment (Sent to PayPal - $36.40)*Fees for Processing your Payment (Sent to PayPal - $36.40)Total $0.00 Payment Method*PayPal Checkout American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name WHAT NEXT?Click PayPal below to PAY and SUBMIT your form to Pamoja Kenya OfficialsFOR OFFICE USE ONLY: Pamoja Kenya ReviewerPlease note: Pamoja Kenya Official must complete this section upon review of this application.Verified by (Name of Pamoja Kenya Official):DateVerified by (Name of Pamoja Kenya Official):Date