Membership Registration

This form will enable ACTLAP to determine your status as a potential Member and assist us in analyzing your application needs.

Incentive

For a yearly Membership fee of (equivalent of $160),  You will receive an ACTLAP Membership Numbered Card and may include an ACTLAP T-Shirt, if you have not been given one. See next page after sending this application.

If you are interested in ACTLAP - UN Member Events, Rep or Participant contact us (+234-803-941-1592 or +234-802-315-5118) to Register. Once Registered as an ACTLAP member with membership fee paid, a Participating/Rep form to attend ACTLAP - UN events will be sent to you and a UN invitation will be sent to you directly to arrange your VISA. You will be required to pay an ALL INCLUSIVE FEE FOR THE TRIP (May cover Return Airfare, Local Transportation for event only, Hotel Reservation only, Breakfast only, UN Ground Pass, Invitation Package

Note: You may be required to send a scanned clear copy of the data page of your valid International Passport * (That's for those Traveling with us for our UN Programs)

BEFORE YOU COMPLETE THIS FORM, YOU CAN

CLICK HERE TO VIEW OUR REGISTERED UNITED NATIONS EVENTS

Note: Required fields are indicated with an *.  Use CAPITAL LETTERS to fill Form

Part One

Salutation
* Mr. Mrs. Ms. Miss Dr. Prince  Chief   Hon
* Male Female

Permanent Mailing Address
*Last Name:  
*First Name:   Second Name:
*Address:  
 
Apartment #: *City:        Province/State:       
*Country:      

Postal Code/ZIP:       
 

Telephone / Fax
Country Code:
 
Home/Cell - Area/Region Code:   Number:      
Work - Area/Region Code: Number: Ext:
FAX - Area/Region Code: Number:
*E-mail Address:      
*Birth Date:
*Month:        *Day:        *Year:       
*Country of Citizenship:
Provide at least any 2 of the following
*International Passport:      
Drivers License Number:
National Identification Number:

*Preferred Language
English French
Other - Please specify:
Occupation:

Employed   Self-Employed  Student  Unemployed

Company/School/Business Name  
*Supervisor First Name:   Second Name:
*Address:  
Suite #: *City:        Province/State:       
*Country:       

Postal Code/ZIP:
 
 

Authorization

I hereby certify that the above information is true and complete. I understand that any false or incomplete information submitted in support of my application may invalidate my application. I have read the Freedom of Information and Protection of Individual Privacy Statement (see below).

Freedom of Information and Protection of Individual Privacy Act:

The information on this form is collected under the legal authority of the Ministry of Information and Technology. The information is used for administration and statistical purposes of ACTLAP and/or the Ministries and Agencies of Government.
For further information, please contact:

ACTLAP Canada
2288-100 City Centre Drive Mississauga, Ontario L5B 3C8 Canada
Tel: +1 (647) 977-7119 | Tel/Fax: +1 (647) 977-7122
GSM: +234 (802) 088-2475 or +234 (803) 237-1818 (Nigeria/Africa Roaming)

email: inf@actlap.com | website: www.actlap.com
*Applicant Signature: By clicking this checkbox, you are agreeing to the terms of the Freedom of Information and Protection of Individual Privacy Act as specified above.

Part Two

How did you first learn about ACTLAP?
Canadian Embassy Resource in your home country
Fair Friend or Relative in Canada
The Internet Friend or Relative at home
ACTLAP Member Publication:
Agent Other:

Who encouraged you to apply?
Counselor Parent
ACTLAP Member Other:

Have you traveled to CANADA OR USA OR SWITZERLAND OR AUSTRIA before
Yes No
If yes, please list the names and addresses of schools, and the programs and dates attended:
Country
City
event
Start Date
End Date
 

Part Three

If you have a contact person in Canada, USA, Switzerland, Austria, please fill out the following section.
Information Release Pursuant to the Freedom of Information and Protection of Individual Privacy Act, I hereby authorize ACTLAP to release any and all information related to any and all aspects of my application for Membership, acceptance, fees or events to the person whose name and address appears below. I certify that the person named is my selected representative and has my agreement to access and use this information to assist me to successfully register and access events with ACTLAP.

I authorize information release to my Emergency Contact:

Applicant Signature: If you have provided information for a Emergency Contact, please read the above terms and click the signature checkbox at left. By clicking this checkbox, you are agreeing to the terms of the Freedom of Information and Protection of Individual Privacy Act as specified above.
 
Emergency Contact's Name and Address
*Contact's Name:  
*Contact's Address:  
*City:  
*Province/State:  

Emergency Contact's Telephone, Fax and E-mail:
*Country Code:  
*Phone/Mobile: Area code: Number: -
 
*Phone/Mobile2: Area code: Number: -
*E-mail address:
Have you checked all your entries and verified that they are correct?

*Do not submit more than one application*

Note: We will contact you to begin the process of your application (See next page after sending application)