CTAC Organizational Membership Application Form

Organization: *

Mailing Address: *

Website:

Email: *

Phone: *

Fax:

The following individual will be the representative of our organization:

Name: *

Last Name: *

Title: *

Office Phone: *

Email: *

If other, describe:

Our organization/group/project has: *

A substantial HIV/AIDS mandate

A partial HIV/AIDS mandate

Please attach your mandate to this application:

Name of board chair or executive director: *

The format in which we would prefer to receive CTAC’s publications and regular mailings is: *

Printed copies by mail

Electronically by e-mail

Either mail or e-mail

Our preferred language of correspondence is: *

English

French

Both

CTAC Mandate: To secure and ensure access to therapies and treatments for people living with HIV/AIDS by working with the public, private and not-for-profit sectors.

CTAC informs research and public policy, and promotes public awareness; provides mentoring and skills building in these areas to people living with HIV/AIDS; encourages and facilitates the exchange of related information to stakeholders; builds and works with coalitions to address broader health care issues impacting access to therapies and treatments.

Yes, we have read and agree with CTAC’s mandate: *

Yes

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CTAC Organizational Membership Application Form

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