1. MEMBERSHIP CATEGORY (Select one)
MEMBERSHIP CATEGORY (Select one)
*
Student Director
Future Director
Certified Director
Member
Fellow
Retired Member
2. PERSONAL DETAILS
Title:
*
Mr
Mrs
Ms
Dr
Prof
Other
Full Name (Surname First):
*
Professional Qualifications (Initials):
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Nationality:
*
National ID / Passport No.:
*
Mobile Number:
*
-
Country Code
-
Area Code
Phone Number
Email Address:
*
example@example.com
Country & City of Residence:
*
3. CURRENT WORK DETAILS
Organisation / Company Name:
*
Current Job Title:
*
Employment Status:
*
Executive
Non-Executive
Consultant
Academic
Retired
Other
Years of Work / Business Experience:
*
Years of Director Experience:
*
Industry / Sector:
*
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4. DIRECTORSHIP EXPERIENCE
Current Directorships (Executive / Non-Executive – list up to 3):
Number 1
*
Please Select
Executive
Non-Executive
Number of Years
*
Number 2
*
Number of Years
*
Number 3
*
Number of Years
*
Past Directorships (if any):
*
5. EDUCATION & TRAINING
Highest Qualification Attained:
*
Have you completed a Director or Corporate Governance Programme?
*
Yes
No
If yes, specify (Institution / Programme):
*
6. KEY AREAS OF EXPERTISE (Select all that apply)
*
Corporate Governance
Strategy & Leadership
Finance & Audit Oversight
Risk & Compliance
Legal & Regulatory
Human Capital & Remuneration
Marketing & Growth
Public Sector / SOEs
Other
7. DIRECTOR PLACEMENT INTEREST
Are you interested in Board Placement Opportunities?
*
Yes
No
8. DECLARATIONS (Tick Yes or No)
*
Rows
Yes
No
Have you ever been convicted of a criminal offence (excluding traffic offences)?
Have you been declared insolvent or disqualified as a director?
Are there any pending proceedings that may affect your suitability as a director?
Have you ever been removed from a professional body for misconduct?
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9. CODE OF CONDUCT & CONSENT
I confirm that the information provided is true and correct. I agree to abide by the Directors Institute Africa Constitution, Code of Conduct, and Membership Rules, and commit to upholding the highest standards of ethical leadership and good governance. I understand that admission into the Professional Director Programme is subject to verification and acceptance by Directors Institute Africa.
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
10. REQUIRED UPLOADS/ATTACHMENTS
Required Uploads/Attachments
*
Curriculum Vitae (PDF)
National ID / Passport
Academic Certificates
Passport-size Photograph
Upload All Required Attachments
*
Browse Files
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Choose a file
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11. REFERRAL & AWARENESS (Optional)
How did you hear about Directors Institute Africa?
*
Website
LinkedIn
Email
Referral
Event
Other
Referrer Name (if any):
*
Submit Application
Successful applicants will be contacted after assessment. Directors Institute Africa reserves the right to request additional information or conduct due diligence.
Section 8: For Official Use Only (DIA)
Application Received By:
Date Received:
Membership Number:
Programme Cohort:
Approved By:
Remarks:
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