V&M Cooperative Society

44, Oyedele Oguniyi str, Anthony Village Tel: 08023132600, 08023081599

TITTLE (Mr/Mrs/Miss/Ms/Others) *

NAME IN FULL (BLOCK LETTERS) *

THROUGH APPOINMENT FULL)

Email Address *

CONTACT ADDRESS *

POSTAL ADDRESS *

DATE OF BIRTH *

PLACE OF BIRTH

NATIONALITY *

STATE OF ORIGIN *

L.G.A OF ORIGIN *

SEX *

HOME TOWN/ VILLAGE OF ORIGIN *

MARITAL STATUS *

ORGANISATION/ DATE OF FIRST APPOINMENT *

IF ON CONTRACT INDICATE WHEN CONTRACT IS TERMINATING/ENDING *

MOBILE NO. *

ALTERNATIVE NO: *

BANK NAME *

ACCOUNT NO *

BANK BRANCH *

ID NO (IF NOT A NIGERIAN) *

NEXT OF KIN (NAME IN FULL) *

DATE OF BIRTH *

RELATIONSHIP *

MOBILE TEL NO *

CURRENT ADDRESS *

Address Line 1

City

State / Province / Region

Country

EMAIL ADDRESS *

MONTHLY CONTRIBUTION YOU WANT TO BE MAKING 10,000, 20,000, 30,000, 40,000, 50,000, 100,000 OTHERS ABOVE 100,000 PLEASE SPECIFY AMOUNT *

MONTHLY CONTRIBUTION TO BE PAID THROUGH (Tick/Appropriate) *

REFERRED BY

SURNAME FIRST

REFERAL'S MEMBERSHIP Number

DECLARATION *

I hereby apply as a member of VILLAGE MARKET MULTIPURPOSE COOPERATIVE. If admitted, I understand and abide by the Rules & bye-laws of the cooperative and shall endeavor to advance in the course of the organization. In certify that the information given on the form is true and correct and enclosed payment for my membership application.