IAWRT Membership Application Form

Full Name Mobile Phone Fax Date of Birth

Preferred Name Work Phone Home Phone Country of Residence

Email Mailing Address

Employer Designation Supervisor's Contact (Name, Phone, Email) Period of Employment Office Address Brief Professional Profile

Highest Education/Training in Media Other Qualifications

Chapter Head (if applicable) Endorsing Member Signature of Endorser

Annual Income Range

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Upload your signature file here:

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I confirm that the information provided is accurate and I agree to IAWRT’s terms.