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Member Registration Form

Fields marked with an asterisk * are required.
Application for* Fellow  Member  Associates  Student Member
Title* Prof  Dr  Mr  Mdm  Ms
First Name*
Last Name*
Home Address*
Office Address
Please select your preferred mailing address* Home Address  Office Address
Telephone (home)*
Telephone (office)
E-mail*
Fax
Date of Birth*
NRIC No./ Passport No.*
Nationality*
Singapore Permanent Residence Yes  No

Professional Qualifications
Period Qualifications / Awarding institution
or Positions / Company Name
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(Expertise / nature of work)
From To

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Payment Details
Payment:   Cheque    American Express    MasterCard    Visa
Cardholder Name:  
Card Number:  
Expiration Date:  
Cheque Number:  
     
Cheques should be made payable to: Singapore National Institute of Chemistry
Supporting documents and payment, should be sent to:

SNIC Secretariat
c/o CMA International Consultants Pte Ltd
1 Liang Seah St
#02-12 Liang Seah Place
Singapore 189022