Application For for Organizational Membership

Application for Individual Membership

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A. Identification
Name / Nom*
Pronouns
Mailing Address / Adresse postale

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone Number / Numéro de téléphone

Country CodeArea CodePhone Number
Email address / Adresse de courrier électronique
D. Your participation in ACIC / Votre participation au sein du CACI
You are applying for / Vous désirez devenir (please do not pay until membership is approved)

Regular membership / Membre régulier ($35 regular / $25 student)To be paid by online / Paiement par en ligneor by Cheque / ou par chèque
How did you hear about ACIC?
Why are you interested in joining ACIC? Please provide 1-3 paragraphs and refer to ACIC's mission and mandate here: www.acic-caci.org/who-we-are.
Do you agree with ACIC's mission? (found here: www.acic-caci.org/who-we-are)
Please state your professional or voluntary affiliations.
What experiences/skills/interests do you bring to ACIC?
Short Personal Biography for ACIC Website (please include any information you would like published on the website, including Facebook, Twitter Handle, Website, LinkedIN, etc)
Please check if you are interested in any of the following areas:

Membership CommitteeSymposium CommitteeGovernance CommitteeInternational Development Week Committee
How did hear about ACIC?/ What or who encouraged you to apply?
The Atlantic Council for International Cooperation (ACIC) is a coalition of individuals, organizations, and institutions working in the Atlantic region, which are committed to achieving global sustainability in a peaceful and healthy environment, with social justice, human dignity, and participation for all.

Yes, I consent to receiving electronic messages from ACIC (including but not limited to emails and newsletter). (PLEASE CHECK)Oui, je consens à recevoir les messages électroniques du CACI (incluant, mais non limité aux courriels et bulletins électroniques) (SVP cochez)
Please sign:

I am familiar with and accept the Goals, Objectives, and By-laws (www.acic-caci.org/who-we-are) of the Atlantic Council for International Cooperation (ACIC), acceptance of which are a condition of membership in ACIC.
Signature

Clear
Date

MonthDayYear
ACIC Members agree with the ACIC mission and promote gender rights and equality, support sexual and reproductive health for all, and uphold human rights that takes into account all forms of discrimination based on sex, race, ethnicity, place of birth, religion, language, sexual orientation, gender identity, age, ability, body size, geography, or migrant or refugee status.

Yes, I agree with this statement.No, I don't agree with this statement.Unsure, but I agree to ongoing dialogue about this.
ACIC encourages and welcomes an open dialogue with our members. If you have any questions, concerns or points to discuss about this statement, please contact Raushni Abraham, ACIC Membership and Operations Manager (raushni@acic-caci.org
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Application for Individual Membership

A. Identification

D. Your participation in ACIC / Votre participation au sein du CACI