Membership Application Form

MEMBERSHIP APPLICATION FORM

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BDUSA

Membership Application Form

Contact Us

Member’s Name(Required)

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Renewing Member

New Member

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First

Mobile Number:(Required)

Home Phone:(Required)

Mailing Address:(Required)

Mailing Address

State / Province / Region

ZIP / Postal Code

Emergency Contact Name(Required)

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Name

Mobile Number(Required)

Home Phone(Required)

Mailing Address(Required)

Email Address(Required)

Married/Single(Required)

If Married Spouse Name(Required)

City

State / Province / Region

ZIP / Postal Code

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MEMBERSHIP PAYMENT

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MEMBERSHIP FEE(Required)

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$10.00 Lifetime membership/subscription for Single (Skip the next section if you selected this option)

$20.00 Lifetime membership/subscription for Family

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Receiver Ofﬁcer

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Signature(Required)

Print Name(Required)

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Paid Online on

Date

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MEMBERSHIP FAMILY MEMBERS UNDER EIGHTEEN

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Details(Required)

Full name

Date of Birth

Relation (S/D)

School Attended

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** For our records, please provide a document that proves your child is under eighteen. The school she/he attends can provide a certiﬁcate of attendance.

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CERTIFICATION - AGREEMENT(Required)

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I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

I declare to have received a copy of the statutes (and possibly of the internal rules) of the association, of which I was able to take knowledge. I declare to commit myself to respect all the obligations of the members of the association which appear there.

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Signature(Required)

Print Name(Required)

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MATRICULATED UNDER REFERENCE

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BDUSA IN REF 2022 – 2023

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Remember to ask a copy of this Membership Form from the Registering Ofﬁcer for your records

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Total

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About Us

BDUSA is a nonprofit organization dedicated to providing support to the Burundian diaspora community. Our mission is to empower Burundians living in the United States by promoting their cultural heritage, providing educational resources, and assisting with various aspects of their lives.

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Contact Info

773 7249 905 bdusafedral@bdusafedral.org 519 13th Ave Rock island, IL 61201

About Us

Useful Links

Quick Links

Contact Info

773 7249 905 bdusafedral@bdusafedral.org 519 13th Ave Rock island, IL 61201

Slide title

BDUSA

Membership Application Form

Contact Us