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CIMCIM MEMBERSHIP APPLICATION FORM
PLEASE TYPE or WRITE LEGIBLY
Last Name:
Mr/Mrs/Ms/Prof/Dr (circle one)
First Name: Sex: F/M (circle one) Date of birth:
Position:
Your Institutions Name:
Professional address:
City: Postal code: Country:
Tel.:
(Please indicate country & area code)
Email:
Institutions Web Site:
Mailing address and e-mail for CIMCIM communications if different from above:
City: Postal code: Country:
Tel.:
(Please indicate country & area code)
e-mail:
YOUR ICOM MEMBERSHIP INFORMATION
___________________________________________________________________________________________
Your ICOM membership number:_____________________
International Committee for which you have registered: ____________________________________________
___________________________________________________________________________________________
If you are applying for ICOM membership at the same time you are applying for CIMCIM membership, please provide the date that you submitted your application to ICOM:
Day: ________ Month:__________________ Year:____________
___________________________________________________________________________________________
Category of ICOM membership held/applied for (tick one):
( Regular (voting) ( Regular (non-voting)
( Student (non-voting) ( Institutional
( Retired Professional (voting)
NON ICOM MEMBERS ONLY:
Please explain below why you are not eligible for ICOM membership or are otherwise unable to join ICOM:
PLEASE RETURN YOUR COMPLETED APPLICATION TO THE CIMCIM SECRETARY
By e-mail:
HYPERLINK "mailto:bstrauchen@horniman.ac.uk" bstrauchen@horniman.ac.uk
By post:
Dr Bradley Strauchen
CIMCIM Secretary
c/o Horniman Museum
100 London Road
London SE23 3PQ
UNITED KINGDOM
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