Affiliated Membership Application

Please complete and click submit. Required fields are marked by an asterisk.

Name of society

include translation into English if appropriate

Contact person/function

Mailing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(include country and area code)

(###)

###

####

Fax

Website

http://

How many members does your society have at present?

Enter number

From which country or region

Enter country(ies) or region(s)

Main activities

Any other information

Date

YYYY

Certification

I/we certify that the information I/we have provided to the IRSCL on this membership application is true and correct.