Name:

Year joined AIESEC: 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Workplace:

Position:

Office Address:

City:

Province:

Country:

Telephone: + - - Fax: + - -

E-mail:

Home Address:

City:

Province:

Country:

Telephone: + - - Fax: + - - Pager:

E-mail:

Gender : Male Female Other

Civil Status: Single Married Divorced

if married , Maiden Name:

Birthdate: January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /

Position : NC officer LCP LCAO VPHRD VPM VPP VPX VPCD VPF VPER DOP PRO HRD staff Projects staff eXchange staff CD Staff Finance Staff P&P staff member if you are a staff member please specify what position:

Course: Year Graduated:

Comments / Additional Information: