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?

    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


    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

    Enter your keyword