MEMBERSHIP APPLICATION

1. Contact Information

First Name(*): Tino

Middle Initial: P.
Last Name(*): Capari Anco
Date of Birth (Month/Day/Year): 03/05/1996
Email(*): tinocaparianco@outlook.es
Cell Phone: +51 920137544
Home Phone: 00-51-1-38857321
Mailing Address
Street(*): Call. Sta Carmela 252
City(*): S.M.P
(
State/Province * :) Lima
( )
Postal Code * : LIMA 09
Country(*): Peru
(*)Important: Be careful what you put in writing without accents, diaresis or hypthens.

2. Business/University Information

Students should provide the name and address of their school/university here.

Job Title: Mining Engineering Student

Organization: Universidad Nacional de Ingenieria
Business Classification: Mining
Street: Av. Tupac Amaru 210
City: Rimac
State/Province: Lima
Postal Code: LIMA 25
Country: Peru

3. Endorser Information (It will be filled by ISEE-UNI Student Chapter)

Name:
Company:
Phone:
ISEE Number:
How long have you known this person?
Relationship:

4. Membership

Membership Type: Student Membership