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Cambodian Men's Network |
Membership Application Form
Registration for the Cambodian Men's Network
Join the network - Your participation is needed!
I am interested in joining the Cambodian Men's Network, please register me.
Given Name:____________________________________________________________
Family Name:___________________________________________________________
Date of Birth:_________________________________ Age:______________________
Job/Position:____________________________________________________________
Name of Organization/Agency/Institution (Acronym & full letters)
______________________________________________________________________
Type of Organization:
1 International NGO
1 Cambodian NGO
1 UN Agency
1 Government Agency
1 Other (please specify)_________________________________________________
Address:______________________________________________________________
_____________________________________________________________________
City / Province:________________________________________________________
Mobile Phone:__________________________________________________________
Phone (Home):_________________________________________________________
Phone (Office):_________________________________________________________
Fax:__________________________________________________________________
E-mail:________________________________________________________________
Check one alternative:
1 I accept that this information is included in the database of the network and can be made available at the website for other members in the future.
1 I do not wish the information to be available for other members at the website
Signature_____________________ Date______________________
Please return the form to Mr. Chhay Kim Sore, GAD/C
# 4, Street 294, Sangkat Tonle Bassac, Khan Chamkarmon, Phnom Penh, Cambodia
P.O. Box 2684 Phnom Penh 3 or Mail Box at CCC: 128 ; Tel/Fax: (023) 215137
Email:
gad@bigpond.com.kh or gad@forum.org.kh