AAA-C Membership Registration Form
Simple Steps to Become a Member of the AAA-C:
 Step1: Complete this online registration application. If you have any query, please direct it to aaac.cambodia@gmail.com.

 Step2: Make a payment for the membership fee of 10USD. The payment can be made at:

o Wing: From any wing outlet to phone number:096 370 2175 (in this case, please send the secret code to 096 370 2175 or to aaac.cambodia@gmail.com)

o AAA-C's Secretariat Office: # 08, St. 600 Corner St. 307, Sangkat Boeung Kak II, Khan Toul Kork, Phnom Penh.
Tel +855 78 23 12 36/ 88 40 29 468
o AAA-C’s Functions


1. PERSONAL DETAILS
Title: *
Family name: *
Your answer
Given name: *
Your answer
Sex: *
Citizenship *
Date of Birth *
MM
/
DD
/
YYYY
Primary Email: *
Your answer
Business Email (Alternative)
(Leave blank if not applicable)
Your answer
Primary Phone: *
Your answer
Business Phone (Alternative)
(Leave blank if not applicable)
Your answer
Home Address *
Your answer
2. ACADEMIC DETAILS
(Please provide your latest qualification.)
Country of University Attended: *
Your answer
Name of University Attended: *
Your answer
Highest Qualification *
(e.g. Degree: Bachelor, Master, PhD)
Major: *
(e.g. Public Health)
Your answer
Date of Commencement:
MM
/
DD
/
YYYY
Date of Completion:
MM
/
DD
/
YYYY
Funding Scheme *
If your funding scheme is scholarship, please provide the scholarship name (example: Australia Awards Scholarship):
Your answer
3. EMPLOYMENT DETAILS:
Job Title: *
Your answer
Name of Organisation: *
Your answer
Other Job (If any)
(Leave blank if not applicable)
Your answer
4. Registration Information
Are you a new member or existing member? *
Which membership category are you registering for? *
Payment Method *
5. Privacy Policy
Note: The above information will be used for data summary purposes, website listing and distribution of newsletters and invitaions. Individual personal information will not be released without your prior approval.
Do you wish to have your name included in membership list made available to the public? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service