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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