ASPAC-NGO Membership Application Form

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Name : *Please specify your name Sirname : *Please specify your sirname
Birthdate (D/M/Y) :  

Age :  Occupation : *Please specify your occupation
Position :  Organization : *Please specify your organization
Mailing Address : *Please specify your mailing address
City/State : *Please specify your city/state Postal Code : *Please specify your postal code
Country :

Tel : *Please specify your telephone no. Fax :
E-Mail Address : *Please specify your e-mail
Membership Category (Choose One Only)*Please specify your membership category
Compose of *Please specify at least 1 person
I, hereby, acknowledge and am pleased to act in compliance with the objectives and missions of ASPAC-NGO stipulated in this brochure and also pledge not to do anything to bring about unfavorable reputation to the Organization.

Enclosed with the application form is the registration fee and annual membership fee in US dollars payable to ASPAC-NGO Secretariat of which the mailing and e-mail addresses appeared in the cover of this brochure.

Signature*Please specify your signature
()*Please specify your signature again