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Name*

E-mail address*

Nationality*

Country of Residence*

Are you*

Provide details of your current (or, if retired, former) main employment or professional activity*

What is/ was the full name of the main institution you work(ed) for?*

What is/was the institution’s main business?*

If you are trainer or lecturer, what kind of courses do/did you work on?*

If you are an author, what are the title(s) and publisher(s) of books you have written?*

If you have undertaken a further qualification or completed an ecml module, what was name and date of the course or module?*

What contact (if any) have you had with Eaquals and Eaquals member institutions?*

How did you find out about Eaquals?*

What are your reasons for wishing to join Eaquals?*

What contribution do you think you could make to Eaquals and its work?*

Any other relevant information

INVOICING DETAILS (Please provide the address where the Individual membership fee should be invoiced to)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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