SAFINA PARTY MEMBERSHIP VERIFICATION FORM

Surname

Other Names

Date of Birth

Gender

ID/Passport Number

Electors Number

Safina Membership Card No. SF

Issued Date

Place of Issue

County

Constituency

Ward

Polling Station

Religion

Ethnicity

Special Interest

Member Telephone

Are you a PWD?

NCPWD Number (if PWD)

Postal Address

Postal Code

Town

Upload ID/Passport Copy (PDF/Image) Max size: 2MB. Accepted: PDF, JPG, PNG

Member's Signature (Type Full Name)

I the undersigned do hereby affirm/declare/verify that I am not a registered member of any other registered political party in Kenya

I verify that I am not a member of any other political party in Kenya

Recruited By

Recruiter Telephone

Date

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