Associate Membership Form

• Your Organisation

• Council Name/Political Group/other Elected Authority*
• Total Annual Budget (capital & revenue)*
• Correspondence Address*
  Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
• Facebook
• Twitter

• Lead Contact

• Title*
  Please SelectMrMrsMsCouncillor
• First Name*
• Last Name*
• Job Title*
• Mobile number*
• Landline number*
• Email address*
  Enter Email Confirm Email

• Your Leader/Mayor (if applicable)

• Please check the box below to enter details for your leader/mayor
  • Enter details
• Title*
  Please SelectMrMrsMsCouncillor
• First Name*
• Last Name*
• Job Title*
• Mobile number*
• Landline number*
• Email address*
  Enter Email Confirm Email
• Twitter

• Your Clerk/Chief Executive (if applicable)

• Please check the box below to enter details for your clerk/chief executive
  • Enter details
• Title
  Please SelectMrMrsMsDr
• First Name
• Last Name
• Job Title
• Mobile number
• Landline number
• Email address
  Enter Email Confirm Email
• Twitter

• Your Officer Network representative (if applicable)

• Please check the box below to enter details for your officer network representative
  • Enter details
• Title*
  Please SelectMrMrsMsDr
• First Name*
• Last Name*
• Job Title*
• Mobile number*
• Landline number*
• Email address*
  Enter Email Confirm Email

• Your Comms/Marketing contact (if applicable)

• Please check the box below to enter details for your comms/marketing contact
  • Enter details
• Title*
  Please SelectMrMrsMsDr
• First Name*
• Last Name*
• Job Title*
• Mobile number*
• Landline number*
• Email address*
  Enter Email Confirm Email

• Your Invoicing contact

• Title*
  Please SelectMrMrsMsDr
• First Name*
• Last Name*
• Job Title*
• Mobile number*
• Landline number*
• Email address*
  Enter Email Confirm Email

• Our Monthly eNewsletter

• We’ll send our monthly eNewsletter to everyone already mentioned. Who else should receive our communications? (Max 10 email addresses per CCIN Member)
  • Add Recipents
• Click the plus button to add further recipients*

  Title	First Name	Last Name	Job Title	Telephone Number	Email Address