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MEMBERSHIP REGISTRATION

(Please read the membership information carefully before filling this form)

Payment Information
Subscriber Within Nigeria
Bank Name:
Branch:
Amount Paid:
Date of Payment:
Mode:
Cheque/Draft/Teller Number:
Society's Current Account Details:
Subscriber Outside Nigeria
Credit Card Type:
Credit Card Number:
(no spaces, no dashes, i.e. 4100111100001111)
Expiration Date:
Personal Information
Title :
Surname :
Other Name(s) :
Date of Birth : Day Month Year
Sex : Male Female
Marital Status :
Nationality
Nigerian State of Origin:
Non-Nigerian Country:

State / Province:
Educational Qualifications
Year: (Format: yyyy e.g. 1990)
Qualifications:
Working Experience
Year: (Format: yyyy - yyyy e.g. 1995 - 1998)
Organisation:
Position Held:
Area of Specialization
/Special Academic Interest
Business/Occupation
Permanent Address
Contact Address
Tel. No. :
Fax :
Email :
(Ensure your email address is correct. You will need it to receive your activation notice)
Cell Phone No. :

Membership Log-In Info.
Membership Type :
Membership ID :
Password :
Confirm Password :


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