Institutional Membership Form

Institutional Membership

INSTITUTIONAL MEMBERSHIP FORM

Membership fee is for the period 01 January 2023 – 31 December 2023 irrespective of the date of joining.

Institutional / Organisational Membership
From all African countries: R14270
From all other countries: US$1480

I hereby apply for/confirm my institution’s membership of IEASA and nominate the following individual/s to represent the institution. Institutional membership representatives must be nominated by the Head of your institution. When appointing a representative, the appointing authority of the Institutional Member, which should typically be the head of the institution, is expected to check that there is no conflict of interest between IEASA’s aims and objectives and the personal, professional or business interests of the person nominated to represent the institution for the purpose of the Association.
DETAILS OF UNIVERSITY / ORGANISATION
Name of Organisation
Organisation Type
Organisation Website
Postal Address
Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Telephone
Please provide mission statement if your organisation is a non-academic organisation.
Max. file size: 64 MB.
DETAILS OF NOMINATED REPRESENTATIVE.
Prefix
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Telephone
Mobile
ALTERNATIVE REPRESENTATIVE (The mechanism of alternates should only be used in exceptional cases. In the interest of continuity, the alternate should always be the same person)
Prefix
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Telephone
Mobile
The Nominated representative will also be on the IEASA Directors Forum. If no, please complete the section below:

Yes

No
I hereby nominate the following individual to represent my institution on the IEASA Directors Forum:
Prefix
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Telephone
Mobile
Extract from the IEASA Constitution (January 2021)

Membership
7.3.2 Responsibilities
7.3.2.1 Members are expected to actively promote and support the furtherance of the Association’s purpose and objectives, within the Association, their member institutions as well as national and international networks.
7.3.2.2 Members are expected to conduct themselves in a professional and ethical manner.
I agree
By ticking the box you agree to the above
Consent
I accept the following:
Electronic Signature Agreement:
By selecting the "I accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I accept" you consent to be legally bound by this Agreement's terms and conditions.
Full Name and Surname of the person completing the form:
First Last
Name
This field is for validation purposes and should be left unchanged.

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Institutional Membership

Membership fee is for the period 01 January 2023 – 31 December 2023 irrespective of the date of joining.

DETAILS OF UNIVERSITY / ORGANISATION

DETAILS OF NOMINATED REPRESENTATIVE.

ALTERNATIVE REPRESENTATIVE (The mechanism of alternates should only be used in exceptional cases. In the interest of continuity, the alternate should always be the same person)