MEMBERSHIP REGISTRATION FORM MEMBERSHIP REGISTRATION FORM Names * Title Browse Full Name Organization Title Browse Contact Address * Title Browse Email * Title Browse Phone * Title Browse Date of Birth Title Browse DD / MM / YYYY QUALIFICATIONS A. PROFESSIONAL (Submit copies of certificates) Title Browse Enter in this format :: EXAMINATION BODY / DATE / EXAMINATION PASSED. e.g. 1. ICA / 2010 / ICAN 2. ACA / 2012 / ACCA B. TERTIARY (Submit copies of certificates) Title Browse Enter in this format :: NAME OF INSTITUTION / PERIOD OF ATTENDANCE / EXAMINATION PASSED AND QUALIFICATION OBTAINED WITH DATES. e.g. 1. UNILAG / 4YRS / FINAL EXAMS - BSC 2007 2. UNICAL / 2YRS / MSC - 2009 Membership of other professional bodies: Title Browse Fill in details of all professional bodies you are a member of above Professional Experience in Arbitration: Title Browse Give Details of your Professional Experience in Arbitration: DECLARATIONI pledge to conduct myself strictly in compliance with the rules and conduct to abide by the laws and bye-laws of the Institute of Construction Industry Arbitrators. I pledge and accept * Title Browse REFEREES: (Must be Corporate Financial Members of the Society)Original Certificates must be sighted before attestation. First Referee First Referee Name (in full) * Title Browse Profession * Title Browse Referee Address * Title Browse Employer Title Browse Position Held Title Browse Second Referee Second Referee Name (in full) * Title Browse Profession * Title Browse Referee Address * Title Browse Employer Title Browse Position Held Title Browse Please send cheque or proof of payment to: [email protected]OrInstitute of Construction Industry Arbitrators,No. 5, Simpson Street, (SHOBO HOUSE) 1st Floor, near High Court of Lagos State, Igbosere Road, Lagos Island, Lagos. Bank Details –• INSTITUTE OF CONSTRUCTION INDUSTRY ARBITRATORS• Account No:1024950551• Bank: UBACheques should be issued in favor of “Institute of Construction Industry Arbitrators”Course Fee: =N= 350, 000 (Three Hundred and Fifty Thousand Naira only) per participant. Submit
