WELCOME TO THE CLUB FOR HEALTH - MAMMOCLUB

( UNITED WOMEN’S ASSOCIATION FOR BREAST CANCER TREATMENT AND CARE )

REGISTRATION FORM

1. SURNAME

2.OTHER NAMES

3. DATE OF BIRTH......... MARITAL STATUS

4. POSTAL ADDRESS

5. RESIDENTIAL ADDRESS

6. TEL: RESIDENTIAL...............................OFFICE

7. OCCUPATION

8. NAME OF SPOUSE................NO OF CHILDREN

9. WOMEN’S GROUP/SOCIAL CLUB YOU BELONG

10. I WISH TO BE REGISTERED AS A MEMBER OF MAMMOCLUB

SIGNATURE.................................................DATE

Please note: 1. Attach 2 (two) stamp-size photos

2. Registration fee: C20,000.00

3. Annual subscription: C50,000.00

ONLY MEMBERS IN GOOD STANDING WILL BE ENTITLED TO BENEFITS

WELCOME TO THE CLUB FOR HEALTH

WELCOME

Contact us for additional information. Your kind donation would be highly appreciated.