MEMBERSHIP APPLICATION FORM

BRICK-FISH MULTIPURPOSE COOPERATIVE

15 PARLIAMENTARY ROAD, CALABAR, CROSS RIVER STATE

BIODATA OF APPLICANT

Name *

Date of Birth (dd/mm/yy) *

Sex *

Male Female

NIN Number *

BVN Number *

Phone Number *

Email Address *

Address of Residence *

LGA of Origin *

Address in LGA of Origin *

Upload Passport Photo *

Accepted formats: JPG, PNG, GIF, WebP (Max 5MB)

MEMBERSHIP SUBSCRIPTION

Select Subscription Type(s) *

Thrift Savings Account Shares Account Market Place Vendor Account

Monthly Thrift Subscription Amount (₦)

Total Shares Subscription Amount (₦)

ONLINE SERVICES SUBSCRIPTION

Member App (Android)

Yes No

Download from Google Play Store

Internet Access (iPhone/Web)

Yes No

Preferred Username

Check your email for default password. You will be required to change it on first login.

NATURE OF BUSINESS

Business Type(s) *

Transport Trade/Commerce Agriculture Fashion/Tailoring Arts and Culture

Business Brand Name

Business Location Address *

NEXT OF KIN INFORMATION

Name of Next of Kin *

Phone Number *

Email Address *

Address of Residence *

Important Information

• Membership Fee: Non-refundable application fee of NGN2,000
• Annual Renewal: NGN1,000 annually (non-refundable)
• Thrift Payment: Due between 1st to 15th of every month. Late payment fee: NGN500
• Annual General Meeting: 14th December every year
• Payment: Pay to FirstBank 3028554078 | Account: Brickfish Multipurpose Cooperative
• Required Documents: Photocopy of NIN and Proof of address (utility bill or rent agreement)

DECLARATION & CONSENT

I declare that the information provided in this membership application is true, accurate, and complete to the best of my knowledge. I consent to Brick-Fish Multipurpose Cooperative using my personal information for membership processing, verification, and communication purposes in accordance with their privacy policy.

Registration fee: ₦2,500 (charged at checkout)