Membership

Step 1 of 3 - Section A

Name*
Title First Last
Gender*
- Male
- Female
Age*
Please enter a number from 18 to 90.
Mobile*
Email*
Enter Email Confirm Email
Address*
Physical Address Postal Address Country

Date of which you qualified as a certified mediator*
Training programme/s you attended.*
Your profession/Occupation.*
Category of membership*
Membership to professional bodies*
Please Indicate Area(s) of Practice as a mediator
Other (please specify)

Date for Assessment
Please submit your form and we will revert to you with a proposed date of assessment.
Checklist for submission of application
Please note, all the requirements below must be fulfilled before progressing to interview for admission into membership of ICMC.
Untitled*
Files
Note
1. The form must be accompanied by Kes. 1,000/- non-refundable application fee payable to ICMC via KCB Bank, Account Number 1237805414, or
MPESA Paybill Number 522522, Account Number 1237805414.
Once the payment is made, kindly send the deposit slip/ MPESA transaction message to info@icmc.or.ke.
2. Once your membership is approved, you will be given a membership number and certificate indicating your status.
3. You will be required to pay the membership fee of Kes. 2,000/- and consequently Kes. 3,000/- as an annual membership subscription.

For further information, please contact us.
Consent*
I agree to the privacy policy & declaration.
PRIVACY POLICY
Persons who supply data in their application to the Mediation Accreditation Committee are advised to note the following points.

1. Personal data provided in this application form will be used solely for the purpose of assessment for accreditation as a Mediator, and in this connection the data herein will be dealt with by the ICMC staff and/or by the Membership and recruitment Committee members.

2. After an application for assessment has been duly processed, the application papers of the candidates will be retained in a file established by the ICMC membership and recruitment Committee for each applicant. Such information will be retained by ICMC Committee for as long as it deems necessary or useful.

3. An applicant has the right to request access to, and the correction of, his/her personal data as retained by the ICMC membership and recruitment Committee.

Declaration
1. I have read and agreed to the Personal Data Notice.

2. I authorize the ICMC membership and recruitment Committee, ICMC staff, employees and/or members of the ICMC Committee to deal with, utilize and/or assess the data submitted by me as may be required in connection with my application for membership as a mediator.

3. I understand that my data will become a part of the ICMC Committee records and may be used for all purposes deemed necessary or useful by the ICMC membership and recruitment Committee.

4. I declare that the information given in support of this application is accurate and complete. I understand that any misrepresentation will disqualify my application and may lead to revocation of my membership as a mediator, should I be enrolled. ICMC membership and recruitment Committee also reserves the right to report the matter
to my professional body/association.

5. Any information on this form may be made available by ICMC membership and recruitment Committee to third parties for the purposes of mediator assessment or
selection.

6. I have no previous criminal convictions for crimes of dishonesty, violence or misuse of drugs. I have no criminal cases pending against me. I undertake to inform ICMC membership and recruitment Committee if I am charged with any criminal offences during the time that I am enrolled to the ICMC mediator membership.

7. I confirm that there are no disciplinary actions against me by any professional body.

Membership

Step 1 of 3 - Section A

Date for Assessment

Checklist for submission of application

Note