Page 88 - KANU Constitution

FIFTH SCHEDULE

KANU MEMBERSHIP FORM

Name ...................................................................................................................

County....................................................................................................................

Constituency .........................................................................................................

Ward......................................................................................................................

Polling Station.......................................................................................................

Religion.................................................................................................................

Disability...............................................................................................................

Gender .................................................................................................................

ID. NO. ................................................................................................................

CONTACT
ADDRESS
P. O. BOX ............................................................................................................

PHYSICAL
ADDRESS: ..........................................................................................................

TELEPHONE NO(S): .........................................................................................

E-MAIL: ..............................................................................................................

MEMBERSHIP CATEGORY (CHOOSE ONE FROM THE LIST BELOW)

SELECTED MEMBERSHIP MEMBERSHIP FEE ANNUAL
NO.
CATEGORY (KES) SUBSCRIPTION FEE
1. Platinum
2. Gold
3. Silver
4. Bronze
5. Imara
6. Corporate

BANK DETAILS OF PAYMENT/MPESA CODE

DATE

SIGNATURE

87