WICCI Membership registration form

    All fields marked with * are required

    Membership Category *

    PatronCorporateGroupIndividual SilverIndividual Bronze

    Mode of payment *

    1. Member Details

    Member Business Name *

    Sector *

    Registration/License number *

    Date of Registration *

    Physical Address/County *

    Postal Address

    Postal/Zip Code

    Email Address *

    Website

    Brief description of products and services

    2. Contact Person Details

    Title

    Surname *

    Other Name(s) *

    ID/Pasport No. *

    Nationality *

    Mobile No. *

    Email Address *

    Physical Address/County *

    Town *

    Postal Address

    Postal/Zip Code

    Next of Kin Name *

    Relationship *

    Mobile No. *

    3. Declaration and Confirmation