Membership Application

Please complete all applicable sections. Fields marked with * are required.

Member Application Form

Name of Organisation Date of Establishment Ownership Structure Legal Constitution

Governance Framework

Is your organisation a not-for-profit entity?

Yes No

If yes, please specify

Briefly explain your organisation's mandate

Organisation Contact Details

Contact Person Name E-mail address Telephone (Office) Telephone (Mobile) Address

Membership Profile

Number of corporate members Number of individual members Number of other members

If other, please specify Main departments in your organisation

Number of employees in your organisation Type of products and services offered

Type of membership you are applying for

Corporate Member Member

As per the ACGN Constitution criteria for membership (Section B.2).

Motivation & Website

Brief motivation for applying for membership Organisation website address

Declaration

I, the undersigned, being authorised to do so by the organisation stated above, hereby apply on its behalf to be admitted as a member of the African Corporate Governance Network (ACGN). I certify that the information in this application is true and correct to the best of my knowledge. If accepted, we agree to comply with and be bound by the Constitution of the ACGN.

Name Capacity Signature (type your full name) Date

I confirm the above statement

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