See Membership Page for Requirements APPLICATION FOR PROFESSIONAL MEMBERSHIP Please complete this Application Form and submit along with your current CV, copies of supporting Qualifications/Certificates, a passport-Sized photograph and an application fee of five thousand naira only (N5,000) payable to ICIMN UBA PLC. AIC NO: 1025505020 SECTION A: CATEGORY OF MEMBERSHIP APPLYING FOR(pls tick as appropriate) FELLOWFULLASSOCIATE SECTION B: APPLICANT'S PERSONAL DETAILS Title First Name Middle Name Surname Name Gender —Please choose an option—MALEFEMALE Date of Birth State of Origin Telephone No Add your Passport photograph Local Government Area WhatsApp No upload you CV Email official/Business Address Residential Address SECTION C:EDUCATIONAL INSTITUTIONS ATTENDED WITH DATE & QUALIFICATIONS OBTAINED Schools attended(Beginning with Tertiary) Certificates & Year of Graduation Schools attended Certificates & Year of Graduation Schools attended Certificates & Year of Graduation Schools attended Certificates & Year of Graduation SECTION D: MEMBERSHIP OF OTHER PROFESSIONAL BODIES/PROFESSIONAL QUALIFICATIONS Name of Institute/Professional Body/Grade/date achieved SECTION E: SUMMARY OF CAREER PROGRESSION/WORKING EXPERIENCE provide information dating back the past five years EMPLOYER/ORGANIZATION + JOB TITLE + DATE SECTION F : DECLARATION I agree that irrespective of the professional membership grade for which I have applied, I will accept the grade of professional membership considered appropriate and awarded me by the Membership Committee of the Institute. Should I be inducted and a Membership Certificate be issued to me, I understand that it remains the property of ICIMN and that I must return it to the Institute upon cessation of membership. I agree to adhere to the Code of Conduct and Membership Regulations of ICIMN. I hereby, submit my application for membership and declare that all the information given on this form is accurate and true. Δ
