CTAC Individual Membership Application Form

Nom : *

Last Name : *

Gender :

Mailing Address : *

Courriel : *

Home Phone : *

Office Phone :

Fax :

I am applying as : *

A person living with HIV/AIDS (Full Individual Membership)

An HIV - or undisclosed person (Associate Individual Membership)

If other, describe :

Important: If you declare your HIV+ status or demographic information above, CTAC will maintain confidentiality as outlined in our privacy policy. To read CTAC’s privacy policy, click here.

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

Either mail or email

Printed copies by mail only

Electronically by e-mail

No printed mail! (By making this selection, I understand I will not receive AGM materials such as election ballots and by-law changes and, therefore, may miss the opportunity to vote at the AGM. I understand I can visit the CTAC office to pick up election materials. I understand I have the option to change the status of how I would prefer to receive mailings at anytime by contacting the CTAC office)

Please note: All communication sent by postal mail will be in non-identified confidential packaging.

My preferred language of correspondence is : *

English

French

Either

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

Yes

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CTAC Individual Membership Application Form

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