LADIES IN MINING AND ALLLIED PROFESSIONS In

GHANA

MEMBERSHIP APPLICATION FORM

*Please fill in BLOCK letters Please insert/attach

*Please note that you are required to fill out all fields a recent passport
sized photo

GENERAL INFORMATION

TITLE (Miss/Mrs/Dr/Prof/Ing etc.):

FIRST NAME(S):

SURNAME(S):

BIRTH DATE (dd/mm):

EMAIL: (Please use your most permanent email address and write as is supposed to appear)

COUNTRY OF BIRTH:

NATIONALITY:

REGION:

CITY:

TOWN:

COUNTRY OF RESIDENCE:

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LADIES IN MINING AND ALLLIED PROFESSIONS In
GHANA

MEMBERSHIP APPLICATION FORM

CITY OF RESIDENCE:

POSTAL ADDRESS:

CONTACT INFORMATION

MOBILE PHONE:

FACEBOOK:

INSTAGRAM

TWITTER:

PROFESSION

NAME OF COMPANY/INSTITUTION:

DESIGNATION/POSITION:

HIGHEST ACADEMIC QUALIFICATION:

COUNTRY (Country where your present company/institution is based):

CITY:

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LADIES IN MINING AND ALLLIED PROFESSIONS In
GHANA

MEMBERSHIP APPLICATION FORM

COMPLETE ADDRESS:

PHONE:

EMAIL:

I ……………………………………………………………….. promise to abide by the

rules and regulations of the Ladies in Mining and Allied Professions in Ghana (LiMAP-
Gh).

DATE:

SIGNATURE: …………………………………..

DATE: ………………………………………….

FOR OFFICE USE ONLY

APPROVED NOT APPROVED

TYPE OF MEMBERSHIP APPROVED: …………………………………………………..

APPROVED BY: …………………………………………………..

POSITION: ……………………………………………………

SIGNATURE: ………………………………….

DATE: ………………………………….

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