Application Pour Devenir Membre

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"Haiti Club For Hope" Application Pour Devenir Membre Enter the information below then submit, fax (561-840-9218), email (haitivision1@yahoo.com) or mail the application to the address below for approval. 1506 Broadway, Suite 2, Riviera Beach, Florida 33404
First Name:
Middle Name:
Last Name:
Phone:
Street Address:
City:
State:
Zip:
DOB:
Occupation:
Country of birth:
City of birth:
Email:
Home Page:
Have you been convicted of any crime in the last 5 years?	No Yes
If yes, please explain:
How did you hear about the institution?
Are you a member of any other organization?	No Yes
If yes, please explain:
From the 12 committees of development of Haiti Vision Inc. type the one(s) you would like to be a part of: Agriculture and raising livestock Water irrigation and energy distribution Economy and finances Commerce and industry Fishing Social affairs Health and life Transportation Education Recreation, environment and tourism Justice and peace Worship, prayer and evangelism
Please list some of the skills you have:
Annual membership fee is $50. Upon approval, please make check or money order payable to Haiti Vision Inc.
Digital Signature:
Date: