2010 LIASA Western Cape Branch Nomination Form

*Closing Date for Nominations is 15 November 2010 *

DETAILS OF NOMINEE:

Name:
Address:
Tel no:
Cell no:
Email:
Library/Institution:
LIASA membership no:
Date of joining:

I/We hereby accept the nomination.


Signature(s) of nominee(s):



DETAILS OF LIBRARY TEAM (if applicable)
Name LIASA Membership No


DETAILS OF PROPOSER:

Name:
Address:
Tel no:
Cell no:
Email:
Library/Institution:
LIASA membership no:
Date of joining:

Signature of proposer:


For office use only