Civil Society Practitioners and Professionals Alumni (CPA)

REGISTRATION INFORMATION

Do you want to register for full membership of CPA?

Yes No

Are you recommended by any person?

Yes No

Please add his/her name:

This is one year renewal, the full membership fee is 100$. Are you ready to pay?

Yes No

PERSONAL DETAILS

Title:

Family name:

Given name:

Sex:

Citizenship: (upload ID card) Cambodian

Date of Birth: (dd-mm-yyyy)

Primary Email:

Business Email: (Alternative) (Leave blank if not applicable)

Primary phone:

Business phone: (Alternative) (Leave blank if not applicable)

Home Address:

Family Status:

Please upload family book

BENEFICIARY
Please give the name of your nominated successor or beneficiary in case of risk (death or disability)

Name:

Sex:

Date of Birth: (dd-mm-yyyy)

Relation Type:

ACADEMIC DETAILS
(Please provide your latest qualification)

Highest Qualification :

Major: (e.g. Public Health)

EMPLOYMENT DETAILS

Job Title:

Name of Organization:

Other Job (If any) (Leave blank if not applicable):

Do you have your own business?
Yes No

Please list their products/services:

PRIVACY POLICY

Note: The above information will be used for data summary purposes, website listing and distribution of newsletters and invitations. Individual personal information will not be released without your prior approval.

Do you wish to have your name included in membership list made available to the public?

Yes No

CPA Membership Registration Form