Application for Membership | Cosbots Membership Website

Date Form Submitted: *

Section 1: Applicant Details

Application for membership.

Surname: *

Full Names: *

Pseudonym / Stage Name: *

Date of Birth: *//

Place Country of Birth: *

Nationality: *

Language: *

National ID / Passport No: *

Gender: *

Marital Status: *

Spouse:

Employment Status: *

Circle of Occupation:

Section 2: Addresses

Physical Address: *

Address Line 1

City

State / Province / Region

Postal Address: *

Address Line 1

City

State / Province / Region

Mobile Number: *

Email:

Website / URL:

Section 3: Right Holder Roles (tick where appropriate)

Upload Artistic Content:

Click or drag files to this area to upload. You can upload up to 10 files.

Section 4: Other Societies

Are you a member of any society: *

If yes please give details:

Section 5: Banking Details

Bank Name:

Account Name:

Branch:

Account Number:

Branch Code:

Payment Method:

Signature Clause:

Please take note that by typing your name you agree to the terms and conditions specified.

I declare that the information given is true and correct, and that I am authorized to sign in my personal capacity. Should any of the above information change at any time, COSBOTS will be notified immediately to avoid any delays in payments, or payment into an incorrect bank account. In addition, I agree and accept that, in the event of the above information being incorrect, COSBOTS will not be held responsible for any delays and/or loss.

Name & Surname:

Section 6: Managed Rights (Membership)

Copyright and neighbouring rights

Membership Status: *

Membership will be provisional until approved by Cosbots.

Region or City (Residence): *

Rights transferred to COSBOTS: *

Territories: *

Section 7: Next of Kin Information

Full Name & Surname: *

ID / Passport Number: *

Relationship: *

Contact Number: *

Next of Kin Address Details: *

Address Line 1

City

State / Province / Region

Next of Kin Details (Other):

ID / Passport Number:

Relationship:

Contact Number:

Next of Kin Address Details:

Address Line 1

City

State / Province / Region

Section 8: Inheritance Information

Beneficiary Full Name & Surname: *

Address: *

Address Line 1

City

State / Province / Region

Mobile Number: *

Signature Clause: *

I accept the following terms and conditions

I hereby apply to be admitted as a member of COSBOTS and declare that the above information is true to the best of my knowledge and that COSBOTS shall not be held accountable in case of any false information provided by myself. I understand that my membership is subject to the membership rules of COSBOTS, the COSBOTS Constitution and the Copyright and Neighbouring Rights Act, therefore my rights, obligations and liabilities as a member shall be governed by the above mentioned statutes, in Botswana.