Online application

ICG Membership Form
Please, kindly complete this form and return to the Institute.

SECTION 1: GENERAL INFORMATION
First Name *
Other Name
Surname Name *
Title:Mr/Mrs/Miss/Dr/Prof. etc
Date of Birth: Date/Month/year

Month Day Year
Date
State of origin
Company Name & Address
Address for Correspondence
Permanent Home Address
Telephone Number *
Fax
E mail Address *
example@example.com
Job Title *
Nature of Work/Business *
SECTION 2: ACADEMIC & PROFESSIONAL QUALIFICATIONS
Attach a copy of your CV and Photocopies of your academic and professional certificates with the application form.

Academic Qualification starting with the most recent.

Professional Qualification starting with the most recent profession (e.g Law, Engineering, Medicine, Banking, Insurance, teaching, Architecture, consulting, professional qualification (eg): NIM, ANAN, ICAN, ACIB, CIS.
File Upload

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SECTION 3: CATEGORY OF MEMBERSHIP YOU ARE APPLYING FOR. Tick as appropriate.
Type of Membership

Corporate Member Full Member Fellow Associate member Licentiate Member Research Fellow Student member
Amount and Details of Bank draft enclosed
SECTION 4: EMPLOYMENT HISTORY.
Attach a pdf copy of employment history (e.g Position held, Responsibilities, Date and Name of organization)

Cancel of
SECTION 5: REFERENCES.
To be completed by people who have known you to some professional capacity, for at least three (3) years
REFEREE (1)
Name
Job Title
Name and Address of Organization
Phone Numbers
Please enter a valid phone number.
Email Address
example@example.com
Comments
Signature

Clear
REFEREE (2)
Name
Job Title
Name and Address of Organization
Phone Numbers
Please enter a valid phone number.
Email Address
example@example.com
Comments
Signature

Clear
REFEREE (3)
Name
Job Title
Name and Address of Organization
Phone Numbers
Please enter a valid phone number.
Email Address
example@example.com
Comments
Signature

Clear
SECTION 7: SUBMISSION OF OFFLINE APPLICATION FORM.

All completed application should be submitted to:

The Registrar/CEO,Institute of Corporate Governance Nigeria, Corporate Governance House, Suite 35, Silla - Zeka Plaza, 29, Adebayo Adedeji Crescent, Off Ajose Adeogun Street, Utako Business District, P.O. Box 16082, Wuse Post Office, Abuja, Nigeria.

E-mail: nstofcorpgovnig@yahoo.com, instofcorpgov@yahoo.com, projectmasterplan@yahoo.com
Name & Signature of officer

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Date

Month Day Year
Date
Should be Empty:

ICG Membership Form

SECTION 2: ACADEMIC & PROFESSIONAL QUALIFICATIONS