Cultural Workers Register
PERSONAL INFORMATION
Email address *
TITLE
FIRST NAME* *
Your answer
MIDDLE NAME*
Your answer
LAST NAME *
Your answer
PROFESSIONAL ARTISTIC NAME
Your answer
DATE OF BIRTH
MM
/
DD
/
YYYY
Gender
AREA OF WORK *
Other
Your answer
ETHNICITY (Optional)
Other
Your answer
CONTACT INFORMATION
ADDRESS 1
Your answer
ADDRESS 2
Your answer
CITY/TOWN/VILLAGE
Your answer
COUNTRY
Your answer
MAILING ADDRESS, IF DIFFERENT FROM ABOVE
MAILING ADDRESS1
Your answer
MAILING ADDRESS 2
Your answer
MAIL CITY
Your answer
MAIL COUNTRY
Your answer
PHONE (Work)
Your answer
MOBILE
Your answer
WEBSITE
Your answer
MEMBERSHIP IN ORGANISATION
ARE YOU A CURRENT MEMBER OF ANY ORGANIZATION *
Required
NAME OF ORGANISATION
Your answer
MEMBERSHIP STATUS
Your answer
YEAR REGISTERED with ORGANIZATION
MM
/
DD
/
YYYY
PROOF OF CITIZENSHIP (Please provide at least one)
ID#
Your answer
PASSPORT#
Your answer
DRIVER’S PERMIT#
Your answer
BANKING INFORMATION
ACCOUNT NAME
Your answer
NAME OF BANK
Other
Your answer
BANK ACCOUNT
Your answer
DATA ENTRY
THIS INFORMATION WAS ENTERED BY:
If Other (please provide name)
Your answer
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