Please print form and proceed to office at 2 Rose Street, Goodwill, Roseau, Dominica to become a member.

 

                                   DOMINICA COUNCIL ON AGEING INC.

               INDIVIDUAL MEMBERSHIP APPLICATION FORM

 

                       Note:   Please fill in this form and return it to the DCOA’s office.

                                         All information will be treated very confidentially.

 

 

1.  NAME: _______________________________________________________________

                        Surname                         First name                   Middle name

 

2.  ADDRESS: ____________________________________________________________

 

                             ____________________________________________________________

 

3. DATE OF BIRTH: ___________________ PLACE OF BIRTH: _______________________

 

4. TELELPHONE:    Home: _________________ Cell: __________________

 

                                          Fax: _________________      Email Address: _______________________

 

5. PRESENT OCCUPATION / PROFESSION: ______________________________________

 

6. OTHER OCCUPATION(S) PROFESSION(S)   PREVIOUSLY HELD______________________

 

_____________________________________________________________________

 

7. ARE YOU OR HAVE YOU BEEN A MEMBER OF

 

a). ANY OTHER GROUPS, CLUB, SOCIETIES, ORGANIZATION (S) ETC. PLEASE TICK

 

____ (a) YES,   I AM;    ___ (b) YES,   I’VE BEEN;    ___ (c)   NO

 

b)  IF YES, GIVE NAME (S) __________________________________________________

 

8a. ARE YOU PRESENTLY HOLDING ANY POST/OFFICE(S) IN ANY OF NO.7 ABOVE?

 

PLEASE CHECK                                        YES ______          NO _____

 

b. NAME THE POST (S) OFFICE (S) ____________________________________________

 

_____________________________________________________________________

 

9. HAVE YOU HELD ANY POST (S) OFFICE (S) IN ANY OF NO. 7 ABOVE?

 

b. NAME THE POST (S)/OFFICE (S) ____________________________________________

 

10.  WHAT ARE YOUR HOBBIES? (a) ___________________________________________

                                                                        (b) ___________________________________________    

                                                                       (c) ___________________________________________  

                                                                       (d) ____________________________________

 

                                                                       (e) ____________________________________

 

                                                                       (f) ____________________________________

 

11. WHY DO YOU WISH TO BE A MEMBER OF THE DCOA INC.?

_____________________________________________________________________

 

_____________________________________________________________________

 

_____________________________________________________________________  

 

12. DO YOU PROMISE TO COMPLY WITH THE RULES AND REGULATIONS OF THE COUNCIL?

                           YES ____                    NO ____

 

(b) WILL YOU BE PREPARED TO ASSIST THE COUNCIL WHEN NECESSARY?

                           YES ____                  NO ____  

______________________________________________________________________

 

THIS SPACE IS FOR OFFICE USE ONLY

 

                        APPROVED:                 ________________________________

 

                       NOT APPROVED        ________________________________

 

                       REMARKS (IF ANY)  ________________________________________________

 

______________________________________________________________________

 

______________________________________________________________________ 

 

                                                                                                               

 ________________________________

 

                                                                                                                                                   SECRETARY

                              

 _________________________________

 

                                                                                                                                                  PRESIDENT