Membership form

MEMBERSHIP FORM

Membership form

(Please send us by email ankober@ethionet.et or postal address 33101, Addis Ababa, Ethiopia)

Full name: __________________________

Sex: ______________

Profession: ________________________________

Membership date: _________________________

Address

Tel: _______________________

Mobile: _________________________

Fax: __________________________

E-mail: __________________________________

Postal Address: ________________________________________

Mode of contribution

If in cash, how much? _________________________________________________________________

If in kind, what? _____________________________________________________________________

If in service, what? _________________________________________________________________

Others: _____________________________________________________________________

Confirmation

Name: __________________________________________

Signature: ______________________________

Date: ___________________

Comments

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________