CTAC Organizational Membership Application Form

Organization : *

Mailing Address : *

Website :

Courriel : *

Phone : *

Fax :

The following individual will be the representative of our organization:

Nom : *

Last Name : *

Titre : *

Office Phone : *

Courriel : *

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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