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MEDIA INSTITUTE OF SOUTHERN AFRICA (MISA) ZAMBIA CHAPTER P.O. Box 32295, Lusaka

Tel: 294285/86

Fax: 292096

INSTITUTIONAL MEMBERSHIP APPLICATION/RENEWAL FORM Name of institution:…………………………………………………………………… Postal address:……………………………………………………………………… Telephone no(s):………………………………………………………………………. Fax no(s):……………………………………………………………………………… E-mail address(es):……………………………………………………………………. Contact person:……………………………………………………………………… Institutional membership fee of K300,000 paid by (name): ……………………… Signature:……………………………………………………………………………… Designation:…………………………………………………………………………… Date:……………………………………………………………………………………. FOR OFFICIAL USE ONLY Payment received by:…………………………………………………………………. Receipt number:………………………………………………………………………. Date:……………………………………………………………………………………. Application approved/rejected.

Date:………………. Signature:………………

Reason for rejection: …………………………………………………………………. ………………………………………………………………………………………….. …………………………………………………………………………………………..

2007 MISA institutional renewal  

Receipt number:………………………………………………………………………. Telephone no(s):………………………………………………………………………. Name of institution:…………………………………………………………………… E-ma...

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