Register – Signature Media Club

Personal details

Full name*

Please enter your full name.

Email address*

Please enter a valid email address.

Phone / WhatsApp number*

Please enter a contact number.

Date of birthoptional

Genderoptional

Marital statusoptional

Blood groupoptional, useful in emergencies

Spouse's nameoptional

National ID / passport numberoptional

Present address*

Please enter your address.

Permanent address is the same as present address

Permanent address*

Please enter your permanent address, or tick the box above.

Photographoptional, passport-size works best

Professional details

This is what tells us who's joining and how to place you within the club.

Current organisation*

Please enter your organisation.

Designation / job title*

Please enter your designation.

Media sector*

Please select a sector.

Years of experience*

Please select a range.

Press ID / employee IDoptional

LinkedIn / portfolio linkoptional

Nominee details

The nominee is who the club contacts about your membership benefits in your absence.

Nominee name*

Please enter a nominee name.

Relationship to you*

Please enter the relationship.

Nominee phone numberoptional

Membership details

Membership type*

General member Associate member Life member

Please choose a membership type.

How did you hear about the club?optional

Why do you want to join?optional, a couple of lines is fine

Payment details

Fill this in once you've paid the membership fee, so it can be matched and verified.

Amount paid*

Please enter the amount paid.

Date of payment*

Please enter the payment date.

Payment method*

bKash Nagad Bank transfer Cash

Please select a payment method.

Transaction / reference IDoptional, required for mobile banking or bank transfer

Upload payment receiptoptional, image or PDF, up to 4MB

That file is too large. Please upload something under 4MB.

Emergency contact

Contact name*

Please enter an emergency contact name.

Contact phone*

Please enter an emergency contact phone.

Relationshipoptional

Declaration

I confirm the information given above is accurate to the best of my knowledge, and I agree to follow the club's code of conduct as a member.

I agree to the above declaration*

Please confirm the declaration to continue.

Type your full name as signature*

Please type your name as signature.

Your details are stored so the club can review applications. Please only submit once.

Application received

Welcome aboard

Your membership application has been recorded. A club coordinator will reach out to confirm your membership.