Name:  Date: 
Home Addr1: 
     Addr2:  
     Phone:  FAX: 
    E-Mail: 

   Company: Title: 
Work Addr1: 
     Addr2:  
     Phone:  FAX: 

    Birth Country:   Birth Date: 
Highest Education:         Date: 
      Institution: 

    Family Status: Single   Divorced  Seperated
                   Married  Number of Children: 

Membership Fee:   Individual  Family  Student
Payment Method:  Cash  Check  Bank&Check #: 

Reference 1:  From: 


Reference 2: From:  

OATH: I declare that I do not belong to any Cambodian political party. However, (if applicable),

I was a member of  from  to 

but I have resigned from it since  (letter of resignation attached).

If accepted, I pledge to uphold and defend the WCC By-Laws and Internal Rules & Regulations
as approved by the Board, and to respect all Board decisions. I will conduct myself in a strictly
professional way and, in case of doubt, will seek the WCC Executive Officer(s) or Board Member(s)
clarifications and guidance's to avoid any appearance of improper behavior.

Comments & Questions:

      
For your record, please also print your application. Thank you.