AFRIKAN CO-OPERATIVE UNION LIMITED

Pooling resources to design our future

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MEMBERSHIP REGISTRATION FORM

PERSONAL DETAILS

Title:______

Forename:______

Surname:______

Address: ______

Town: ______

County: ______

Postcode:______

Home Tel: ______

Mobile: ______

E-mail: ______

ETHNIC ORIGIN

Nationality: ______

Gender: ______

Date of Birth: ______

How would you describe yourself

A Black or Black British

African

Caribbean

Any other Black background, please write in box ......

B Mixed Heritage

White and Black African

White and Black Caribbean

Any other Mixed background, please write in box ......

C Any other background, please write in the box......

OCCUPATION (Optional)

Employed Full Time _____ Part time_____ Self-Employed_____ Unemployed _____ Student _____

What is your profession: ______

YOUR MEMBERSHIP

How did you hear about the Afrikan Co-operative Union?

Publication / reference in which seen (if applicable):

______

Are there any other organisations that you are a member, which share similar objects as the Afrikan Co-operative Union?

______

What inspired you to join the Afrikan Co-operative Union?

Please tick all that apply to you

[ ] Cultural/Heritage

[ ] Financial Investment

[ ] Networking Forum

[ ] Afrikan Solidarity

Comment:

______

Membership Fee & Purchase of Minimum 1 Share

Please enclose a membership fee of £30 & £50 for 1 share as per section 5.1 of the ACU Constitution (refundable if application is turned down)

Bank Details

The Co-operative Bank, Name of Account: Afrikan Co-operative Union Ltd Account No; 65491308

Sort Code 08-92-99

Please use First and Surname as reference for ease of tracking by Treasury Department

Declaration

I confirm that all the information I have given is true and correct to the best of my knowledge.

I am aware that personal data (including where relevant, sensitive personal data) relating to myself, whether obtained from myself or from any other source, will be retained by Afrikan Co-operative and/or any of its associated and/or subsidiary companies indefinitely for the purposes of providing me with the Co-operative services.

Signed: ______

Print Name: ______Date: ______

NOTE: Make sure that you attach a Photo I.D. Proof of residence in UK to this application form. Photos with dark glasses or caps covering the forehead are not acceptable:

Acceptable Documents include: Passport or Drivers’ Licence (Photo ID)

& a copy of any one of the following documents: Utility Bill, Bank Statement, Council Tax Bill etc

1

Afrikan Co-operative Union Ltd is registered under the Industrial and Provident Societies Acts 1965

FCA(No.31807R)

Registered address:Suite 126,The Wenta Business Centre, 1 Electric Avenue, Enfield, Middlesex EN3 7XU

W: E: T: 020 8350 8556