The 18^th JCI Academy Registration Form

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Title:

Mr. Mrs. Ms. 　

Full Name, as it appears on your passport:

Date of Birth:(DD/MM/YYYY) :

Nationality:

Passport Number:

Profession/Occupation:

Address:

ZIP code & Country :

Office telephone & Office fax:

Home telephone & Cellular/Mobile:

Email:

English Ability & Smoke:

Fluent Intermediate Basic NO YES

JUNIOR CHAMBER INFORMATION

JCI Senator No:

Highest level of education:

Specify any special dietary:

LOM name:

NOM name:

NOM President Name:

NOM President e-mail:

Current position at NOM level:

Year:

LOM NOM JCI Position:

Year:

LOM NOM JCI Position:

Year:

LOM NOM JCI Position:

Year:

2004 LOM NOM JCI Position:

Year:

2005 LOM NOM JCI Position:

Why do you want to apply
for the 18th Academy?:

Application date(DD/MM/YY):

Applicant Signature:

National President Signature