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Personal Information
Full Name:
Email Address:
Work Phone:
Cell Phone:
Street Address:
City:
Zip / Postal Code:
Country:
Financial Data
Membership Dues Paid :-		$ (Annual Membership Fees is $25.00/Adult)
Donation :-
Member :-
Signature :-
Date :-

Confidentiality :- This registration data shall be kept confidential and shall not be used
for any other purposes than for the membership record of the Nigerian Association of
Manitoba, Inc.