| Membership type |
(*) |
Personal details
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| Salutation: |
(Mr, Ms, Dr, Prof, etc.) |
| Given name(s): |
(*) |
| Family name: |
(*) |
Contact Info
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| Email: |
(*) |
| Confirm-Email: |
(*) |
| Telephone (Work): |
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| Home: |
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| Mobile: |
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Address for Correspondence
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| Address: |
(*) |
| Address (continued): |
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| City / Town: |
(*) |
| Country / State: |
(*) |
| Postcode / Zip: |
(*) |
| Country: |
(*) |
Company Details
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| |
Corporate Membership: I wish to represent my company
Please note that, if you wish your company to be registered as the member, you must check this option and the Company Name will be required. |
| Company: |
(*) |
| Job Title: |
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Company address if different from personal address
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| Address: |
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| Address(continued): |
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| City: |
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| Country / State: |
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| Postcode / Zip: |
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| Country: |
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Declaration |
| I hereby agree to the terms and conditions of membership of the Firebird Foundation (Inc.) as defined in the Rules and Objectives of the Firebird Foundation (Inc.). (*) |
| Click the button to send your application to your email client. From there, just use your email client's Send button to dispatch your application. |
|
| (*) — Indicates a required field. |
Please do NOT try to pay your subscription fee until your name appears in the Member List once your application has been approved.
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