Membership Application Form

Please complete the Members Application Form

* Required fields

Company Name: *

(Membership is per Company)

Address 1: *

Address 2:

Town/City: *

County/Province/State: *

Zip/Postcode: *

Country: *

Member Representative Name: *

(Nominated representative of Member Company)

Job Title: *

Email: *

Contact Tel: *

(Include country & area codes)

Password: *

Re-enter Password: *

(Select a password to use once your membership has been approved)

Membership Invoices will be issued to the address above, unless you indicate a different address in the box below:

All members must meet the following requirements and tick the boxes below:

	Anti Trust – I confirm I have read and agreed with the MIRA Anti Trust rules and regulations.
	Articles of Association – I confirm I have read and agreed with the MIRA Anti Trust rules and regulations

Comments

I hereby agree to pay the membership subscription (as per current fees) according to the invoice payment terms.