Ethiopian Community Association in Atlanta, Inc Registration Form

Ethiopian Community Association in Atlanta, Inc

5616 Memorial Dr. Stone Mountain, GA 30083

Mailing Address: PO Box 494 Clarkston, GA 30021

Phone: 404-298-4570 / 404-254-0747

Office Hours
Monday - Friday: 10 AM to 6 PM
Saturday: 9 AM to 2 PM
ECCA Registration Form
Membership Type*
Full Name*

PrefixFirst NameMiddle Name or InitialLast Name
Date of Birth*

MonthDayYear
Date
Telephone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Permanent Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is billing address the same as Permanent address?*
Billing Address Address*

Street Address

Street Address Line 2

CityState

Zip Code
Martial Status*
Spouse Name*

PrefixFirst NameMiddle Name or InitialLast Name
Spouse Date of Birth*

MonthDayYear
Date
Spouse Telephone Number*
Please enter a valid phone number.
Spouse Email*

Confirmation Emailexample@example.com
Designated Representative 1 Name*

PrefixFirst NameMiddle Name or InitialLast Name
Designated Representative 1 Telephone Number*
Please enter a valid phone number.
Designated Representative 1 Email

Confirmation Emailexample@example.com
Designated Representative 2 Name*

PrefixFirst NameMiddle Name or InitialLast Name
Designated Representative 2 Telephone Number*
Please enter a valid phone number.
Designated Representative 2 Email

Confirmation Emailexample@example.com
Do you have children?*
How Many Children are 18 years or below*
Child 1 Full Name*

First NameMiddle Name or InitialLast Name
Child 1 Date of Birth*

MonthDayYear
Date
Child 2 Full Name*

First NameMiddle Name or InitialLast Name
Child 2 Date of Birth*

MonthDayYear
Date
Child 3 Full Name*

First NameMiddle Name or InitialLast Name
Child 3 Date of Birth*

MonthDayYear
Date
Child 4 Full Name*

First NameMiddle Name or InitialLast Name
Child 4 Date of Birth*

MonthDayYear
Date
Child 5 Full Name*

First NameMiddle Name or InitialLast Name
Child 5 Date of Birth*

MonthDayYear
Date
Child 6 Full Name*

First NameMiddle Name or InitialLast Name
Child 6 Date of Birth*

MonthDayYear
Date
Child 7 Full Name*

First NameMiddle Name or InitialLast Name
Child 7 Date of Birth*

MonthDayYear
Date
Child 8 Full Name*

First NameMiddle Name or InitialLast Name
Child 8 Date of Birth*

MonthDayYear
Date
Child 9 Full Name*

First NameMiddle Name or InitialLast Name
Child 9 Date of Birth*

MonthDayYear
Date
Child 10 Full Name*

First NameMiddle Name or InitialLast Name
Child 10 Date of Birth*

MonthDayYear
Date
Disclosure:

This Edir will be active after 6 months from the registration date. I hereby apply for Participation in ECAA and agree to fully adhere to the spirit and regulations of ECAA as stated therein. I acknowledge that ECAA Regulations may change from time to time and that I agree to be fully bound by terms of the regulations effective on the date of the individual (s) covered by ECAA. I also certify that the information provided above is and in support of this application is true and correct.

Confirmation:

BY SIGNING BELOW I CONFIRM I HAVE READ AGREE TO THE ABOVE DISCLOSURE.
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