GOTABGAA FAMILY FOUNDATION FUND Benevolence Fund Registration Form
You can contact us at coordinator.gotabgaa@gmail.com or visit our website @ www.Gotabgaa.org for more information or if needing assistance with any portion of this application process. To pay the Benevolence Fund Registration fee, visit http://www.gotabgaa.org/members-area .
Email address *
Please Indicate your Full Name *
An initiative of GOTABGAA INTERNATIONAL ORGANIZATION INC.
Please Indicate your Phone Number *
Please Indicate your Home Address *
Your ID Number & type of ID (Passport/DL/State ID) *
Please Indicate your Date of Birth *
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Please Indicate the name of your Spouse (If applicable) *
Please Indicate your spouse's Date of Birth (If applicable) *
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The phone number of your Spouse (If applicable)
Please Indicate the First Designated Beneficiary of the Benefit Payout: Full Names and Contact Information (and percentage of payout if indicated) *
Please Indicate the First Designated Beneficiary's Date of Birth (optional)
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Please Indicate the Second Designated Beneficiary of the Benefit Payout: Full Names and Contact Information (and percentage of payout if indicated) *
Please Indicate the Second Designated Beneficiary's Date of Birth (optional)
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Please Indicate the Third Designated Beneficiary of the Benefit Payout: Full Names and Contact Information (and percentage of payout if indicated) *
Please Indicate the Third Designated Beneficiary's Date of Birth (optional)
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Please List The Names of All Your Biological or USA Legally Adopted Children to be Covered by the Benevolence Fund *
Please List The Names of All Your Biological Siblings Who Share The SAME MOTHER & FATHER With You (step-brothers, step-sisters or adopted siblings are NOT to be listed) to be Covered by the Benevolence Fund *
Please List The Names of Your Biological Parents (If You were adopted prior to turning 18 years old, you may list the name of the adoptive parent) to be Covered by the Benevolence Fund *
By signing this document, you are declaring that: *
Required
Please sign this document by typing your Initials below: *
Endorsement Section.
(To be filled only by the endorser)
For the Endorser: Sign this document ONLY after verifying that the information filled out and the family relationships contained in this Registration Form are accurate to the best of Your knowledge. Any falsification or fraud will result in the termination of benefits and expulsion of both the applicant and the endorser from the Benevolence Fund as stipulated in the Benevolence Fund Policies. Please sign this document by typing your FULL NAME Below:
For the Endorser: Date of Endorsement
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