NTCA ORGANIZATION FORM

Organization 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.

Oranization Information

When was your organization founded ?
State / Geo-political Zone
Organizational Coverage Area/Reach
Organization Thematic Areas

Oranization Registration

Date of Registration
CAC Registration
No of Staff
Volunteers

Oranization 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?

GOVERNANCE

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 Yes, specify
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?

CONTACT INFORMATION (For Returning Members Only)

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

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

Reference 1

Contact Name
Position
Organization
Address
Telephone
Email
Relationship with reference

Reference 2

Contact Name
Position
Organization
Address
Telephone
Email
Relationship with reference

Please Send The Following Document

1. Organization's Constitution

2. Annual report

3. Financial Statement

4. Reports of past Tobacco Control Activities

Certification

Name
Date
Position

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