Application for Individual Membership to American Chamber of

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.