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 NORTH CENTRALNORTH EASTNORTH WESTSOUTH EASTSOUTH SOUTHSOUTH WEST Organizational Coverage Area/Reach LocalStateZonalNational Organization Thematic Areas Oranization Registration Date of Registration CAC Registration YesNo 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 AgreeDecline GOVERNANCE Organizational Governance structure Is your organization under the authority of a government department? YesNo If Yes, specify Does Your Organization have a Board of Trustee/Governing body YesNo If Yes, specify How many members constitute the body? Membership in NTCA Is your Organization a member of NTCA in the past? YesNo Have you/your Organization ever received funding from a Tobacco Industry or do you have any alliance with any Tobacco Industry? YesNo 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 YesNo 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
