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 Oromo SOCIETY OF Science and Technology

Membership Application

 

Applicant Information

Last Name   First   M.I.   Date  
Job Tittle  
 

Mailing Address:     Home         Business   

Street Address   Apartment/Unit #  
City   State   ZIP/Postal Code  
Country  
 
Gender:               Female               Male  
 

 

Contact Information

Home Phone   Business Phone  
primary e-mail address   Secondary e-mail address  
 
Education
 Diploma   Date   University/College  
Degree (1)   Date   University/College  
Degree (2)   Date   University/College  
Degree (3)   Date   University/College  
Majors  
 
Birth
Date of birth Month   Day   Year  
Place of birth City   Region   Country  
                                         
Professional Experience in relevance to OSST
Summary of the latest Professional Activity  
Wished field of contribution to OSST, if relevant  
How did you come to know of OSST  

 

Applicant Signature                                                                                               Date