Membership Application

AGOLA KAPOK

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Member's Name

First

Last

Member's date of birth

MM/DD/YYYY

Place of Birth

Sub-clan

Year you moved to North America

Country of Residence

United States of America
Canada

City of Residence

State/Region of Residence

Phone Number

Marital Status

Single
Married
Divorced
Widowed

Name of Spouse

First

Last

Age

Total Number in Household

Number of Childern/Dependents

Name of First Child

First

Last

Age of First Child

Name of Second Child

First

Last

Age of Second Child

Name of Third Child

First

Last

Age of Third Child

Name of Fourth Child

First

Last

Age of Fourth Child

Name of Fifth Child

First

Last

Age of Fifth Child

Name of Sixth Child

First

Last

Age of Sixth Child

Information for Additional Children

Permission & Agreement

I agree and give my permission

I give permission to Agol Kapuk North America to gather and store my information.

AGOLA KAPOK

Welcome to the official website of the Agola Kapuk North America (AKNA). We are a community-based organization composed of members from the larger Acholi Sudanese community residing in North America.

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