REGISTRATION FORM

NATIONAL ID:

Date

FOR OFFICE USE ONLY #

Enter Month , Date, And Year Of Birth *

Select Districts From #1 TO 17 *

Please select Training Center closer to you *

Select your Prefix *

Select your Surfix *

Please provide your legal full name (First, Middle and Last Name)

First Name

Middle Name

Last Name

Select Your Surfix *

Please provide the full contact information of your Community Leader

Block Leader full Name

Block Leader Contact Number

Do you drive a Motorcycle?

Contact Number

Are you a due paying member of any (MRO) in or out of Liberia?

Contact Number

Name Of Origination

Please provide some information about your driving and vehicle use skill

Are you self taught or an individual or institution taught you?

If yes, were you taught at an accredited school, if yes, name?

If no, please list the full name of the individual

Individual Trainer contact Number

Institution contact Number

Name of institution Instructor

Please provide us some information about your vehicle owned or operating

Make/Brand (Click drop down for listing)

Do you own a (2) or (3) wheeler?

If yes, please provide year of manufactured

How long have you been driving?

If two (2) wheelers, please select detail

Select Bajaj 3 wheelers Motorcycle Make, Year & Model

Please provide us some information about your community participation

Are you a due paying member of any (Motorcycle riders organization, MRO) in or out of Liberia, if yes ,please list organization?

ABATE of Liberia/Contact

NAFOMTAL/Contact #:

Name: /Contact #

FOMTUL/ Contact #

Are you a due paying member of any (Civil society organzation, CSO) or Church)?or out of Liberia, if yes ,please list organization? #

Bikers Prayer Service/Contact #

Browne Baptist Church/Contact #

Bikers Credit Union/Contact #

St. Paul Church/Contact #

Please provide the full number of any one of the below Government issued ID

National ID Card #

NEC Voter Registration ID Card #

Liberia's Driver License #

Valid Passport #

Please upload the front copy of your National ID Card

No file chosen

Have you ever undergone any Computer training before?

If yes, list the Trainer or School name

If no, are you interested to learn basic computer intro?

Please take a selfie picture of yourself

No file chosen

Please list at least two persons to contact in case of any emergency

First Name

Relationship to person # 1

Email Address

Phone

First Name

Relationship to person # 2

Email Address

Phone

Please provide name and referral code of how you learned of LIB MSP training program

NAFOMTAL CODE #

FOMTUL CODE #

INDIVIDUAL/BUSINESS CODE #

MEDIA INSTITUTION CODE#

Referral Program: Get commission on every person you refer that make full payment of their training fee to LIBMSP

NAFOMTAL CODE #

FOMTUL CODE #

NEWSPAPER CODE #

INDIVIDUAL/BUSINESS CODE #

RADIO STATION CODE #

THE 6TH BUSINESS CODE #

Full Name

Phone

Full Name

Phone

Full Name

Phone

Full Name

Phone

Full Name

Phone

Mobile Payment Information

MTN MOBILE MONEY

LRD

CASHAPP

USD

MTN MOBILE MONEY

USD

ORANGE MOBILE MONEY

USD

Venmo

USD

PAYPAL

USD

SENDWAVE (International Money Transfer)

USD

ORANGE MOBILE MONEY

LRD

ZELLE.

USD

TAPTAP (International Money Transfer)

USD

Bank Payment Information #

Bank Address: Tubman Blvd. & S.D. Cooper Intersection, Paynesville, Montserrado Co. Liberia A/C Title : LIB MSP

United States Dollars Account #:

USD

Liberian Dollars Account #:

LRD

Account Title: LIBMSP

USD