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 MaleFemale 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)? YesNo Where did you hear about NTCA What are your expectations of NTCA membership? Have you been arrested and or convicted for any crime before? YesNo If yes please provide a brief details Do you smoke or use any tobacco products? YesNo Are you associated with any Tobacco Industry or its activities YesNo 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 AgreeDecline
