AIPI Accountability Movement - Membership Application

A. Personal Details Required

Title

Full Name(s) *

Surname *

ID / Passport Number

Date of Birth

Nationality

Gender (Optional)

Occupation

Employer / Organisation

Email Address *

Mobile Number *

Alternative Contact Number

Residential Address

City

Province

Country

B. Membership Category Required

Please select ONE category you are applying for.

C. Founding Status Optional

Complete only if applicable

Founding Director

Founding Member

Not Applicable

D. Organisation Details Optional

For Companies and Institutions only

Organisation Name

Registration Number

Organisation Type

Position Held

Website

E. Professional Profile

Highest Qualification

Professional Registration (if applicable)

Years of Experience

F. Why do you want to join AIPI?

G. How would you like to contribute?

Tick all that apply

H. Declaration of Role Integrity

I understand that:

My membership does not automatically confer governance authority.
I will perform only the responsibilities associated with my approved membership category.
I will uphold AIPI's Constitution, policies, Code of Ethics and governance framework.

I agree to the Declaration of Role Integrity

I. Conflict of Interest

I have no conflict of interest

I declare a conflict of interest

J. Confidentiality & NDA

I acknowledge that, in the course of my participation in the AIPI Accountability Movement, I may have access to confidential information. I agree to keep all such information confidential, not to disclose it to any third party without AIPI's prior written authorisation, and to use it solely for purposes connected with my approved role. This obligation continues after my membership or association with AIPI ends.

I agree to the Confidentiality & NDA

K. POPIA Consent

I consent to AIPI collecting and processing my personal information in accordance with the Protection of Personal Information Act, 2013.

Yes

No

L. Communication Preferences

Preferred method of communication

Email

SMS

Telephone

Microsoft Teams

Zoom

M. References Leadership & Advisors

Compulsory only for Executive Leadership, Advisors, Patrons and Envoys

Reference 1

Name

Organisation

Telephone

Email

Reference 2

Name

Organisation

Telephone

Email

N. Declaration Digital Signature

I, the undersigned, declare that:

The information contained in this application is true and correct.
I agree to comply with the Constitution, policies, Code of Ethics, confidentiality obligations and governance framework of the Accountability & Integrity Policy Institute (AIPI).
I understand that AIPI may verify the information provided.

I agree to this declaration (digital signature)