IMC Union Regional Secretariat Application Form IMC

1. Are you agree with IMC Union Regulations and framework? Yes No 2. Are you willing to be the IMC Union Council member and Regional Secretariat IMC Yes No 3. If Yes in above two questions, please provide the following information The formal English name and abbreviation of your organization The Type of your organization Address and Post Code The Vice- President of IMC Union Council your organization recommended Name Tel Biography Sex() Title E-mail

The Secretariat of IMC Union in your country (region) IMC Secretary General Name Office Tel () Fax Biography Sex() Title Mobile Phone Email

Web site() Signature Date

Note Successful Application will be confirmed by return E-mail.