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Walia Special Edition on the Bale Mountains (2011) - Zoologische ...

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I. Pers<strong>on</strong>al details<br />

Ethiopian Wildlife & Natural History Society<br />

Membership Registrati<strong>on</strong> Form<br />

1. Dr/ Mr/Mrs/Ms: ________ 2. Full Name:_____________________________________<br />

3. Sex (M/F) : ____________ 4. Date of Birth (dd-mm-yy)*: _______________<br />

5. Place of Birth*:___________ 6. Nati<strong>on</strong>ality: ___________________<br />

7. Qualificati<strong>on</strong> (Dip, BA, MA, BSc, MSc, etc.): ______________________<br />

8. Field of Study: _______________________________________<br />

9. Occupati<strong>on</strong>: _________________________________________<br />

10. Organizati<strong>on</strong>: ________________________________________<br />

11. Positi<strong>on</strong>: ______________________________<br />

II. C<strong>on</strong>tact Address<br />

12. Country: __________________________ 13. State: ______________________<br />

14. City/Town: _________________________ 15. Subcity: ___________________<br />

16. Kebelle: ___________________________ 17. H. No*: ____________________<br />

18. P. O. Box: _________________________ 19. Tel (Office): ________________<br />

20. Tel (Home): ________________________ 21. Mobile: ___________________<br />

22. Fax: ______________________________<br />

24. Website: ___________________________<br />

* Opti<strong>on</strong>al<br />

23. E-Mail: ___________________<br />

III. membership Category<br />

Please tick <strong>the</strong> membership category that most suits you:<br />

Membership Category Subscripti<strong>on</strong> Fee<br />

1. Ordinary Member Birr 60.00<br />

2. Family Member (Ethiopians) Birr 125.00<br />

3. Elementary School Students (Grades 1-6) Birr 5.00<br />

4. Sec<strong>on</strong>dary School Students (Grades 7-12) Birr 10.00<br />

5. Colleges and University Students Birr 15.00<br />

6. Nature/Wildlife Clubs, Schools & CBOs Birr 45.00<br />

7. Instituti<strong>on</strong>s (NGOs, GOs, Colleges and Universities) Birr 100.00<br />

8. Corporate members (profit making organizati<strong>on</strong>s) Birr 500.00<br />

9. Supporting Members (Resident Expatriates and<br />

Ethiopians by Birth) US$ 20.00<br />

10. Life Members (Resident Ethiopians) Birr 1500.00<br />

11. Life Members (Resident Expatriates) Birr 2500.00<br />

<str<strong>on</strong>g>Walia</str<strong>on</strong>g>-<str<strong>on</strong>g>Special</str<strong>on</strong>g> <str<strong>on</strong>g>Editi<strong>on</strong></str<strong>on</strong>g> <strong>on</strong> <strong>the</strong> <strong>Bale</strong> <strong>Mountains</strong> 339

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