*Name
Title	Mr. Mrs. Mr. Ms. Dr. Prof.
Phone
GSM Number
Fax
*Email address
*Address
Are you a politician	Yes No
List of Membership of political party/pressure group
Are you interested in running for a public office?	Yes No
List areas that you can contribute to the work of RG (you may tick more than one):	Fundraising Strategising General Mobilisation Women Mobilisation Youth Mobilisation Professional Class Mobilisation
List not more than 5 recent offices that you have occupied in an association, political party or professional association:
Financial Commitment:
How much can you contribute to, or raise for RG in the first instance?
How much time can you commit to RG’s campaign weekly?
Comments:
In addition, I have read -- and pledge to do all that is necessary towards the achievement of -- the vision, mission and goals of RG.