Universal Zulu Nation - Membership Application

Personal Information

First (Birth) Name

Last (Birth) Name

Other Names

Other Names	Date	State

Date of Birth

Place of Birth

Nationality

Height

Weight

Eye Color

Contact Information

Current Mailing Address

Email Address

Home Phone

Work Phone

Cell Phone

Any Other Contact Information

Education & Employment

Education History

Name of School	Location	Date Attended	Subject	Level/Qualification	Grade

Current Employment

Current Employer

Occupation

Employer Address

City

State

ZIP Code

Military/Government Service

Are You Employed by any Federal or State Agency?

Yes

Have you served in the military?

Yes

Medical History

Do you have any physical disabilities?

Yes

Do you have any mental health conditions?

Yes

Do you have any learning difficulties?

Yes

Date of last physical checkup examination:

Family History

Mother's Side

Grandmother's family name

Grandfather's family name

Great Grandmother's family name

Great Grandfather's family name

Father's Side

Grandmother's family name

Grandfather's family name

Great Grandmother's family name

Great Grandfather's family name

About You

What are your hobbies and/or Interests?

Why do you want to become a member of the Universal Zulu nation?

What do you know about the Universal Zulu Nation?

What skills do you have to offer the Universal Zulu Nation?

What ideas could you contribute to the Universal Zulu Nation?

What is your opinion of honesty?

What is your opinion of loyalty?

Certification & Payment

Membership Payment

Youth Membership

$25.00

For members under 18

Pay with PayPal

Adult Membership

$60.00

For members 18 and older

Pay with PayPal

Upload Payment Proof Please upload a screenshot or photo of your payment confirmation

Select Membership Type

Youth Membership ($25.00) - Under 18

Adult Membership ($60.00) - 18 and older

Attach Photo: Please upload a clear, recent photo of yourself

Attach Signature: Please upload a clear image of your signature

Name Printed:

Date:

This statement certifies that this request for membership was made and this application was completed by myself, the information on this form are true and complete to the best of my knowledge. I know that false information or misleading information may result in disqualification and cancellation of my membership.

I affirm that all information provided in this application is true and accurate

Membership Application Form