Company CHAPEL OF GRACE TRANSFORMATION MINISTRY “Always with You” MEMBERSHIP FORM Please fill out this carefully and correctly. Thank you. Surname * First Name * Middle Name * Telephone Number * Sex * Male Female Birth date e.g: 10/06/1999 Email Address * State of Origin/LGA * Abia Adamawa Akwa-Ibom Anambra Bauchi Bayelsa Benue Borno Cross-River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT Residential Address * Date of New Birth e.g: 10/06/1999 Ever attended Believers Foundation Class? Yes No If Yes, When and where? Name of last church you attended & Location: Highest Educational Qualification * Age Group * 18-22 23-30 31 -35 36- 40 45-50 51- 60 61 -70 70+ Employment status * Unemployed Private sector employed Public sector employed Self-employed Please indicate your profession/vocation Marital status * Single Married Separated Divorced Single Parent Widow Widower If married, state name of spouse Tel. No. of spouse If you have children, how many? Next of kin, if different from spouse Tel I hereby affirm that the information given above is correct to the best of my knowledge. I agree to be held responsible for any false declaration. * Yes No
