Individual Application Form 
Personal Details
Membership Type * Please select your Membership type from the list
Years
Membership Fee

Receive 5% Discount for 2 years payment / Receive 10% Discount for 3 years and more payment.
Title / Prefix  *
First Name  *
Last Name  *
Date of Birth  * Day Month Year
Gender 
Email Address  *
Alternative Email Address  *
Street Address (or Postal Address)  *
Apartment Suite
Postal/Zip Code
City   *

Country   *

Telephone    *

Please include the dialing area code
Areas of Work/Interest

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Other(s), Specify :
Communications
What kinds of information would you like to recieve from CIVICUS

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Preferred Language
Please select the language you are most comfortable communicating in. The Civicus Secretariat may also occasionally send you emails and other forms of communication in this language.
Other Spoken Languages
Other :

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Subscriptions
e-CIVICUS - Our weekly electronic newsletter keeping thousands of people and organizations informed of the developments that are taking place in civil society around the world
Other notifications - CIVICUS will email you with information based on the areas of interest selected above
CIVICUS Mission, Vision and Policy *
I have read and understand CIVICUS' Mission and Vision  *
I have read and understand CIVICUS' Membership Policy  *
I have read and understand the CIVICUS Code of Conduct for Individual Members  *
Disclaimer - Privacy Policy
Yes, I would like to share my contact details within the CIVICUS network
Yes, I want you to feature me on the CIVICUS website
We will never make your contact details available outside of CIVICUS Network. We will only contact you according to the selections you have made above. See our Privacy Policy



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