Membership Membership Package Individual Young CEO Title Title First Name Last Name Date of Birth Nationality Organisation Designation Phone Email Annual Turnover Number of Employees Contact Person Name Surname Phone Email Physical Address Street Address City State/Region/Province Country Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor-Leste) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon The Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Please indicate your sector/s by placing a tick in the boxes that are relevant. As many boxes as appropriate may be ticked if more than one category is applicable. FINANCE Insurance Banking Financial Services ENERGY AND MINING Exploration Manufacturing & Distribution Alternative Energy EDUCATION Primary & Secondary Higher & Tertiary TELECOMMUNICATIONS AND IT Hardware and Equipment Software and Services Telecom Services UTILITIES Water Gas Electricity TOURISM Aviation & travel Hotels, Restaurants & Leisure Services INDUSTRY & TRADE Consumer Staples Food, Beverages & Tobacco Household & Personal Products HEALTH Equipment & Services Pharmaceuticals CONSTRUCTION Materials Goods & Services CONSUMER DISCRETIONARY Automobiles & Components Consumer Durables & Apparel OTHER SECTORS Agriculture Retail Transport & Logistics Media Industrial Chemicals Other If Other, Specify Referred for membership by: Agrina Charity Gillian Pardon Prisca Ropafadzo Tatenda Other If Other, Specify Sign I hereby apply for Individual Membership of CEO Africa Roundtable Submit
