Sri Lanka Muslim Media Forum Membership No

Membership Application Form

SLMMF

01. Name with initials: Mr./Ms. ......................................................................................................................

02. Pen Names: ............................................................................................................................................

03. Postal address: ........................................................................................................................................
District .............................................. Province: ..............................................

04. Telephone Residence: ...................................... Office: ..................................................

Mobile: ............................................ E-mail....................................................
05. Date of birth: ................................................ Age: .......................

06. National Identity Card No.:.............................................

07. Place of work / Media Institution: ............................................................................................................
08. Designation: ......................................................................

09. Nature of work: ................................................. ( Permanent / On contract / Free-lance )

10. Date of appointment at the present place of work: ...................................................
11. Institution/s where applicant worked before:

Institution Designation From To

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12. Educational Qualifications: ....................................................................................................................

13. Professional Qualification & experience: .............................................................................................
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14. Have received any professional training? Yes / No

( If yes please give details ) .................................................................................................................
15. Have you authored any book? Yes / No

( If yes please give details ) .................................................................................................................

16. Are you a member of any other media association? Yes / No
Association Designation

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I hereby agree to abide by the constitution of the Sri Lanka Muslim Media Forum and solemnly pledge
to cooperate with all its activities to achieve the objectives of the Forum.

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Date: ............................ Signature

Proposed by:...................................................... Seconded by:................................................