Ugandan Professionals Network Registration Form: Name

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Ugandan Professionals Network

Staying Connected As Professionals


Registration Form
To apply for membership please complete all questions.

Name: ____________________
First Name

Gender: Female

____________________
Last Name

Male

Address
St Address ______________________ St Address Line 2 _______________
City __________________ State_________ Postal /Zip Code _________

E-mail ____________________________________________________
Telephone
Cell #________________________ Home #

_______________________

Mailing Address (if different from the above)


___________________________________________________________
___________________________________________________________

Signature ________________________

Date ________________

Annual Membership fee: $50, Make checks payable to;

Ugandan Professionals Network


Return any paper registration forms with payment to:
Ugandan Professionals Network
15 Main St, Suite 282
Watertown, Ma, 02472

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