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Organisation Profile

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.

GOVERNANCE

CONTACT INFORMATION (for returning members only)

REFERENCES: Provide two reference persons for your Organization (Preferably members of your Board of Directors’

Please list the names and addresses of three (3) organizations or individuals involved in

Please send the following document

1. Organization’s Constitution
2. Annual report
3. Financial Statement
4. Reports of past Tobacco Control Activities



  • section 1


  • section 2


  • section 3


  • section 4


  • section 5

Organization Information

When was your organization founded ?

State / Geo-political Zone

Organizational Coverage Area/Reach

Organization Thematic Areas

Organization Registration

Date of Registration

CAC registration

No of Staff

Volunteers

Organization Income

What are your Organization’s sources of income?

What is your organization’s annual revenue? (in local currency / USD equivalent)

What other National body/Coalition/Alliance is your organization member of?

Organizational Governance structure

Is your organization under the authority of a government department?

If Yes, specify

Does Your Organization have a Board of Trustee/Governing body

If the answer is yes, what is the name of this governing body?

How many members constitute the body?

Membership in NTCA

Is your Organization a member of NTCA in the past?

Have you/your Organization ever received funding from a Tobacco Industry or do you have any alliance with any Tobacco Industry?

Please clarify specific relationship

Where did you hear about NTCA?

In which programmes, regions or projects would you like to partner with NTCA?

What are your expectations of NTCA membership?

NTCA Contact

When did you join NTCA

Where did you join NTCA

Please describe Tobacco Control activities you have conducted within the last one year

Will you be willing to share your report with us

If yes kindly upload the report alongside other documents before submitting this from


Main NTCA CONTACT (Contact person for your organization)

Name

Direct email

Direct Phone

Chief Executive Officer/ Executive Director Contact

Name

Direct Email

Direct Phone

Other key position Contact

Name

Direct Email

Direct Phone

Reference 1

Contact Name

Position

Organization

Address

Telephone

Email

Relationship with reference

Reference 2

Contact Name

Position

Organization

Address

Telephone

Email

Relationship with reference

Certification

Name:

Date:

Position :

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