South Sudan Institute of Democracy & Peace

SSIDP Membership Registration Form

To apply for membership into the South Sudan Institute of Democracy & Peace, please fill out this form to the best of your ability. You can also download and print out the SSIDP Membership Form in Microsoft Word format to mail to the SSIDP office if you prefer. Contact SSIDP with any questions.

1. Full Name
(Last) (First) (Middle)

2. Preferred Name

3. Date of Birth

4. Place of Birth

5. (a) Nationality

(b) Have you acquired any permanent residence?
Yes No If yes, name the country:

(c) In which country are you currently domicile?

6. Permanent Address

Street	Apt. or P.O. Box
City	State/Provincve
ZIP Code

Primary Telephone (including area code)
Secondary Telephone (including area code)
Email

7. Current Address (only if different from above)

Street	Apt. or P.O. Box
City	State/Provincve
ZIP Code

8. Level of Education
(a) Schools, Colleges, or Universities and dates attended:
(Please, start with the most recent and end with your high/secondary school.)

(b) Certificates, diplomas, and degrees obtained and the years they were obtained:

(b) Brief description of courses taken at each school, college, or university:

9. Skills

Please, list technical skills, clerical skills, administrative and managerial skills, trade skills, etc., relevant to the mission, objective, aim, programs, purposes, and the activities of SSIPD. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert).

10. Payment (check all that apply)
(a) US $50.00 (fifty) SSIDP Membership Registration Fee (This is a one-time fee only.)
(b) US $5.00 (five) SSIDP Monthly Membership Subscription (You may pay US $60.00 (sixty) for the whole year.)
(c) $ Any amount you wish to pay as a contribution, gift, or donation to the Institute.

(d) Please check the form of payment you will make to SSIDP:
I will pay online by credit card.
I will mail a check to SSIDP.

11. Certification

I do certify that the information on this Membership registration Form are accurate and complete. I understand that, joining the Institute is voluntary and I promise to uphold, respect, and protect the Articles of Incorporation, Corporate By-Laws, and the Constitution of South Sudan Institute of Democracy and Peace, Inc., and I shall do all that I can to the best of my ability and power, to work in accordance with the provisions of the Articles of Incorporation, the By-Laws, and the Constitution of the Institute. I also understand that, failure to fully complete the Membership Registration Form, or misrepresentation or omission of facts, represents grounds for withholding, rejection, and or suspension, withdrawal, or termination of my membership after being registered. I authorize South Sudan Institute of Democracy and Peace to investigate, without liability, all statements contained in this form. I also authorize all references, without liability, to make full response to any enquiries. I promise to pay US $ 50.00 nonrefundable one time membership registration fee, and US $ 5.00 monthly membership subscription to the Institute.

After submitting the membership application, please make your payment to SSIDP in the way you noted above. If mailing a payment by check, please use the address below:

South Sudan Institute of Democracy and Peace, Incorporated
229 Carter Avenue, SE
Atlanta, GA 30317-3303 USA

Applicant's Full Name
Today's Date