MISA ZAMBIA INDIVIDUAL MEMBERSHIP APPLICATION/RENEWAL FORM SECTION ONE: (TO BE COMPLETED BY APPLICANT) Name: ……………………………………………………………………………….…. Job title:………………………………………………………………………………… Employer……………………………………………………………………………….. Postal address: …………………………………………………………………………. Telephone no(s): …………………………………………………………….…………. Fax no(s): ………………………………………………………………………………. E-mail address(es): …………………………………………………………………….. Date:………………………………..
Signature: ………………………
SECTION TWO: (TO BE COMPLETED BY A PAID-UP MISA ZAMBIA MEMBER) I ………………………………………….. a bonafide paid-up member of MISA ZAMBIA have known the applicant Mr/Ms. …………………………… for ………... year(s). I recommend/don’t recommend the application. Date: ………………………
Signature: ………………………………………
FOR OFFICIAL USE ONLY Payment received by: …………………………
Date: ……………………………
Receipt number: ……………………………… SECTION THREE: (TO BE SIGNED BY MISA ZAMBIA BOARD MEMBER) I ………………………………………………… a MISA ZAMBIA Board Member have known the applicant Dr./Mr./Mrs./Ms./Miss …………………………….. for …….. year(s). I approve/don’t approve the application. 1
Date: …………………………………
Signature: ………………………
SECTION FOUR: (TO BE COMPLETED BY MISA ZAMBIA CHAIRPERSON) The MISA ZAMBIA board which met on …………………….. approved/rejected the application. Date: ……………………………
Signature: ………………………………
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