IMC Membership Application Form

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1. All fields in this application form are compulsory. Where information is not applicable, a "N.A." is necessary.
2. All necessary supporting documents must be submitted together with your application.
3. Please contact the IMC Armenia Director if you have any enquiries. Tel. 093406842

4. Please enclose your recent CV.

IMC Armenia Membership you are applying for

Affiliate (AFIMC Armenia) Associate (AIMC Armenia) Member (MIMCenia)

Insert your photo here

PERSONAL INFORMATION

Name in full

Postal address (full)

Mobile telephone No

Office telephone No

Home telephone No

E-mail address

AREA OF EXPERTIZE OF APPLICANT
Note: This refers to the area of expertise of the applicant only, and not the area of expertise of his/her firm.

EDUCATIONAL AND PROFESSIONAL QUALIFICAITONS
Note: Please provide copies of certificate

Name of Institution

From

Educational Standard Attained

Note: Please provide copies of certificate

Description of professional qualification

Date admitted

EMPLOYMENT HISTORY

Name of Company and Nature of Business

From

Position and responsibilities

REFERENCIES
Note: For Associate Membership, please provide two IMC Armenia Member references.

DECLARATION BY APPLICANT

1. I declare that the information provided in this application and the accompanying information supporting documents are true and correct to the best of my knowledge and that I have not withheld/distorted any material facts.
2. I agree that the Institute of Management Consultants, IMC Armenia has the right to verify and obtain information with all parties as they think fit, with regards to the information and supporting documents provided by me in this application.
3. I hereby agree that I will strictly adhere to the Code of Professional Conduct and prevailing rules and regulations for consultants prescribed by the Institute of Management Consultants of Armenia.

4. I also agree to play an active role in contributing to the development of IMC Armenia, and will follow the rules of fee payment made at least once a quarter (3 months):

Affiliate (AFIMC Armenia), 1,000 AMD/month Associate (AIMC Armenia), 2,500 AMD/month Member (MIMC Armenia), 5,000 AMD/month

Bank Information
INSTITUTE OF MANAGEMENT CONSULTING OF ARMENIA
AMD Account No.: 1570013587690100
EUR Account No.: 1570013587690146
AMERIABANK CJSC
YEREVAN, ARMENIA
SWIFT code: ARMIAM22

Note: For the signature, scan your signature and insert as image.

Signature of Applicant

Date