Membership Application - Institute of Municipal Engineering of Southern Africa

Membership Category appyling for (select from list): *

Applicant Details

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Title

First Names *

Known As (Greeting/Nickname)

Surname *

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ID or Passport Number

Population Group (select from list)

Gender (select from list)

Date of Birth (mm/dd/yyyy) *

Citizenship (specify if not South Africa)

Disability (select from list)

Contact Details

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Primary Email *

Mobile Phone *

Alternative Email

Work Phone

Physical Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Invoicing Details

Company/Organisation Name

VAT Reg. Number

Invoice Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Delivery of IMIESA Magazine *

Digital copy to Download
Printed copy by Post

Postal Address for deliveries

Address Line 1

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Postal Code

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Applicant Details

Contact Details

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Technical Experience, Professional Registration and Qualifications

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