Membership Form

 

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Fill in this registration form on behalf of your organization to become a  member of the "Tobacco free India coalition."

Organization/NGO

Type of organization

Year of Registration  [YYYY]

Postal Address of the organization

State

City/Town and District

E-mail address of the organization

E-mail address of the CEO

Website

STD Codes

Telephone Number (Office)

Fax  Number

 Area of  specialization of your organization

Approximate number of members/volunteers of the organization

Would your organization like to become a "Regional Coordinator" or a "State Coordinator" for all tobacco related activities in your region/state?

Represented by (Person filling up this form)

Designation of the representative to the coalition

Name of the Chief Executive

Mobile Number

Does your office maintain a tobacco-free environment?

Do you observe tobacco-free environment during the official meetings/seminars/ activities of your organization?

What is the approximate per-annum expenditure of your organization on tobacco control related activities.

Does your organization or any of its members associated with any tobacco company/organisation, affiliate, subsidiary, etc. or hold shares of any tobacco company or its affiliate, subsidiary or associate;

If Yes please provide complete details. Any concealment of information shall be treated as breach of trust. Provider of incorrect information shall be liable for legal action besides immediate termination of membership with costs.

Would your organization like to become "District Coordinator" for all tobacco related activities in your district?

 Please provide a brief paragraph (Maximum 200 words) about the activities of your organization.

I understand that the membership of the "Tobacco Free India Coalition" is subject to acceptance. I also understand that the membership for the above mentioned organization, represented by its members and representatives  is subject to adhering to the terms and the condition applying to the membership of the coalition. I on behalf of my organization agree to abide by all such terms and the condition in full. I declare that I am authorized to fill up this membership form on behalf of the above-mentioned organization.

 

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