LEADERS QUARTERS EMPOWERMENT

Membership Registration Form

Kindly fill in block letters.

Date (DD/MM/YYYY):
12/02/2021

1. Personal Details

Name (Surname First): Omotayo Adeshina Iyanuoluwa

Gender: male Date of Birth (Month & Day): 08/13

Marital Status: single

State of Origin: Ekiti

Home Address: Ile mimo Avenue, Oke Osun Ikere

Ekiti

Profession (specify if you are a student): Student

Company/Organisation’s Name:

Work Address:

School: Afe Babalola University

Personal Mobile Number: 08133454144

Office Mobile Number:

Email Address: adeblessed@gmail.com

Monthly Savings Amount (in Naira): 5000 naira

(A regular amount you plan/decide to contribute on a monthly basis. Your
contribution should however not go below the minimum threshold which is
NGN 3000)
 2. Next of Kin Details

Name (Surname First): omotayo Adedoyin

Address: 4labi exposure photography studio Ijemikin, Arakale, Akure

Ondo State

Phone Number: 08079945369

Email Address: omo2fyndoyin@gmail.com

AFFIDAVIT

I, Omotayo Adeshina , do hereby

swear and affirm that all the information given above in support of this
application are true and correct to the best of my
knowledge.

Signature: A.O Date: 12/02/2021

President’s Name & Signature Secretary’s Name & Signature

PS: Kindly send in your filled form to lqempowerment@gmail.com . Application for loan
and other enquiries would also be through this same email address. WhatsApp
Udeme on +234 708 378 7938 for further enquiry.