Membership Application Form
Personal Details
Title
Select Title
Dr.
Prof.
Mr.
Miss
Mrs
Gender
Select gender
Male
Female
Fullname:(Surname First)
Date of Birth:
State of Origin
-State of origin-
Abia
Abuja
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Edo
Ekiti
Enugu
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
Nationality
Qualification:
Obtained Date
Upload Certificate
Institution
Qualification:
Obtained Date
Upload Certificate
Institution
Qualification:
Obtained Date
Upload Certificate
Institution
Employment Detail
Area of Specialization/Academic Interest
Business Occupation:
Employer:
Office Address:
Permanent Address Information
Address:
City:
State:
Country:
Contact Address Information
(Postal Address)
Address:
City:
State:
Country:
Phone:
Next of KIN Details
Full Name:
Address:
Phone:
What type of membership are you applying for ?
--Select Membership Type--
Associate Member- 15,000
Full Member- 20,000
Institutional - 150,000
Corporate - 500,000
(Select as appropriate)
Attach your passport photograph:
Dimension (600x600), max image size allowed 600kb
Login Details
Email
Password
Confirm Password
I hereby certify that the information given in this form is genuine and correct. I accept to be disqualified upon False information.
