Application for Individual Membership to American Chamber of Commerce in Cambodia (AMCHAM) Individual Applicant Middle Name First/Given Name Last/Family Name Name: Email Address: Date of Birth (dd/mm/yyyy): Nationality: Antigua Angola Andorra Algeria Albania Afghanistan Bosnia Bolivia Bhutan Benin Belize Belgium Belarus Barbados Bangladesh Bahrain Bahamas Azerbaijan Austria Australia Armenia Argentina Cape Canada Cameroon Cambodia Burundi Burkina Bulgaria Brunei Brazil Botswana Central Congo Comoros Colombia China Chile Chad Costa Czech Cyprus Cuba Croatia Dominican Dominica Djibouti Denmark East El Egypt Ecuador Equatorial Ireland Iraq Iran Indonesia India Iceland Hungary Honduras Haiti Guyana Guinea-Bissau Guinea Guatemala Grenada Greece Ghana Germany Georgia Gambia Gabon France Finland Fiji Ethiopia Estonia Eritrea Ivory Italy Israel Kiribati Kenya Kazakhstan Jordan Japan Jamaica Korea Marshall Malta Mali Maldives Malaysia Malawi Madagascar Macedonia Luxembourg Lithuania Liechtenstein Libya Liberia Lesotho Lebanon Latvia Laos Kyrgyzstan Kuwait Kosovo Myanmar, Mozambique Morocco Montenegro Mongolia Monaco Moldova Micronesia Mexico Mauritius Mauritania New Netherlands Nepal Nauru Namibia Papua Panama Palau Pakistan Oman Norway Nigeria Niger Nicaragua Russian Romania Qatar Portugal Poland Philippines Peru Paraguay Rwanda St Saint San Samoa Sao Saudi Sierra Seychelles Serbia Senegal Solomon Slovenia Slovakia Singapore Somalia South Sri Spain Trinidad Tonga Togo Thailand Tanzania Tajikistan Taiwan Syria Switzerland Sweden Swaziland Suriname Sudan Ukraine Uganda Tuvalu Turkmenistan Turkey Tunisia United Vatican Vanuatu Uzbekistan Uruguay Zimbabwe Zambia Yemen Vietnam Venezuela Kitts Lucia Salvador Lanka Tome Marino Timor Zealand Vincent Verde Coast Arabia Rica Leone Africa Sudan North South Republic New {Democratic Herzegovina Arab Kingdom States {Republic} & African City Federation &Islands &Nevis & Deps {Burma} Guinea Tobago Republic Guinea Principe Emirates & Rep the Grenadines Rep} Company Address in Cambodia: Telephone: Website: Please provide a brief description of your activities / business interest: What aspects of AmCham are you particularly interested in? Monthly meetings with speakers: Advocacy: Networking: Social Activities: What committees are you particularly interested in? Membership: Education: Legal, Taxation & Governance: Real Estate & Construction: Events & Programs: Young Professionals: Corporate Social Responsibility: Other (Please Specify): Non-Voting Member - Individual: U.S. $100.00 1. Please print, sign and submit application to AmCham office by email or dropping it off at the AmCham office. a. Once application is received, it will be submitted to the Board of Governors for Approval. b. Once approved, the AmCham office will notify you and provide you an invoice. i. We prorate the amount based upon remainder of membership year (July 1st - June 30th) 2. After receiving invoice, please remit payment to American Chamber of Commerce in Cambodia. a. Payment methods (cheque, bank transfer, credit card or cash) I certify that the statements above are true and to the best of my knowledge. Signature Typed Name Date (dd/mm/yyyy) Print Clicking Print will print a copy of the form for signature, to be scanned and submitted to the AmCham Office. It will also email a copy of your unsigned file to our Office so we ensure the accuracy of the information for posting into your profile on the AmCham web site.