I apply for membership as a/an

          Individual              Corporate                 Academic    

   Type of Membership

          Active                   Associate                    Honorary

1. Surname :   

2. Other Names :   
                                      ( of individual or contact name for organisation)

3. Organisation :
                              (for an organisation only)

4. Present employment:
                                             ( for individual only)

5. Position in present employment:
                                                                (for individual only)          

     (a)  Title or designation:

     (b)  Date of employment to present position:

6.  Postal Address:

7.  E-mail:

8.  Phone(s):

9.  Fax(es):

10. Educational and professional qualification:

QUALIFICATION (INCLUDE DISCIPLINE)  INSTITUTION DATE
 

 

 

    

11. Membership of internet society? (International):

    (a)Are you already a member of internet society?  Yes       No

    (b) If yes, your membership number:

    (c) If no, do you wish to be a member by this application? Yes     No

 

(Note that membership of the internet body is a prerequisite for admission into the Nigeria Chapter. Both memberships could be secured by opting for YES in 11(c) above)

12. Membership of other professional bodies (Specify membership type & grade):      

 

FEES PAYABLE

(a)  Individual:

1.  Annual Subscription for Nigeria Chapter     N1,000.00

2.  Membership fee  Nigeria Chapter               N2,500.00

       3.  ISOC (International) Membership      $12.00 ( or  N1000.00)

(b)  Corporate:

 

All payments should be in favour of  Internet Society Nigeria Chapter by bank draft, cheque, or credit card to the Financial Secretary and obtain official receipt.(Please include two (2) passport size photographs ).

Declaration by applicant:

I declare that the statements made herein are correct to the best of my knowledge, and that I agree to be governed by the constitution/by-laws/regulation of the Internet Society Nigeria Chapter as they exist now and as they may from time to time be amended or enacted. My membership may be withdrawn if it is discovered that I deliberately supplied wrong information.

       Signature of Applicant:        Date:

14. Recommendation by a member

I, a member of Internet Society Nigerian Chapter hereby certify that is a fit and proper person/company to be admitted into the society.

Signature            Date   

OFFICIAL USE

Remark by Approving Officer:

 Signature            Date