MEMBERSHIP APPLICATION

PERSONAL INFORMATION

Name: _______________________________________________

Postal address: ______________________________________

P.O.Box: ____________________       Zip code: _____________

Telephone: _____________________ Fax: __________________

Personal E mail: ___________________ Mobile: _____________

Residence telephone: ___________________

I would like to receive all EERA correspondence by:

   e-mail                     fax

Membership categories :

   Associate member :  annual membership fees : LE 500  

  Voting member : LE 500 enrolment fee 1st year + LE 1000 annual    membership fees

I would like to pay the        associate            voting membership fees

Name:                                                         Date:                       

ID:                       (copy enclosed)

Nationality:

Signature:  ______________________

NOTE : Please submit the application form with 2 recent photos and business card to Mohamed Kharma – Tel : 010-2405850, e-mail : mailbag@endurance-egypt.org

EERA Board of directors' approval:___________________