membership registration form MEMBERSHIP APPLICATION FORM Before Submission, a payment of 5,000 for the Membership Application form should be made HERE or via the TSA Account on REMITA platform. You are to log on to www.remita.net, and click on “pay federal government agency.” From the list of agencies, choose “Institute of Chartered Chemists of Nigeria”, indicate the amount, purpose of payment etc. Application form should be returned with the following: a. Two recent Passport photographs b. Copies of Academic and Professional Certificates c. NYSC discharge Certificate/ Exemption letter d. Photocopy of evidence of payment e. Referees’ reports in confidential cover f. Detailed Curriculum vitae to include the following information: i. Institutions attended and qualifications obtained with dates ii. Professional courses attended in the last five (5) years with dates iii. Detailed work experience with names of organizations and dates iv. Present appointment (Job Title) with date. send all attachments to this email: icconapplicationformsubmission@gmail.com PERSONAL DATA Title Prof. Dr. Mr. Mrs. Miss. Name * Name First First Last Last Home Address * PLACE OF ORIGIN City State LGA Country Date Of Birth * Gender * Male Female Maritual Status Married Single Email Correspondence Address Town State Country Office Address Designation Telephone Schools Attended/Qualifications with Dates Work Experiences with Dates Membership Professional Association Nationality * TIN No National Id No. * Driver's Licence Voter's ID International Passport Referees Download this form and send to your referees to provide their required information, forms should be sent to: (icconapplicationformsubmission@gmail.com) i Names, Membership Numbers and addresses of referees who must be members of ICCON. Contact (Phone Numbers/E-mail) ii Names, Membership Numbers and addresses of referees who must be members of ICCON. Contact (Phone Numbers/E-mail) PAYMENT DETAILS Bank Name/Branch * Amount Paid RRR/ Receipt Number * Declaration * I Declare I hereby declare that the above information provided is the best of my knwledge and correct. If you are human, leave this field blank. Submit
