SOCIETY FOR IMPLEMENTATION OF AFFIRMATIVE ACTIONS AND COMBATING OF BIAS CRIME {SIAA&CBC}

FORM OF MEMBERSHIP

PHOTO OF MEMBER

NAME:

Father/Husband`s Name:

Date of Birth:

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Area of interest:
EngineeringEducationLawHealthSportsCAITOther (Please specify)
Do you want to become Life Member or Member:
Life MemberMember
Any other information:

DECLARATION
I have read and understood objectives of the {SIAA&CBC} and Rules of the Society {SIAA&CBC} and I agree with all the terms and conditions.
SIGNATURE