NTCA INDIVIDUAL FORM

Individual Form

We urge you to fill this form accurately. Information supplied will be saved in the Alliance’s database and will be used for future correspondences with you.

Name
Age
Sex
Contact Address
Qualification
Organization (If any)
Describe your past activities on Tobacco Control (if any)
Briefly explain why you want to join the Alliance?
Would you be willing to volunteer for any of the Aliance activity (if there are oppourtunities)?
Where did you hear about NTCA
What are your expectations of NTCA membership?
Have you been arrested and or convicted for any crime before?
If yes please provide a brief details
Do you smoke or use any tobacco products?
Are you associated with any Tobacco Industry or its activities
If yes please provide a brief details

This is to certify that the information provided here are accurate and correct to the best of my knowledge. We promise our Organization shall be a functional, dutiful and loyal member of the Alliance. We shall fully cooperate with the Alliance and abide by its regulations. We will play our part to ensure a smoke-free Nigeria



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