Faith to Action Network

Membership Application Form

Name of the Organization:

Contact Person:

Position/Title:

Brief Professional Personal Profile:

PhysicalPostal Address:

Telephone: Mobile No:

Fax: Email:

Website:______

Other key contacts in the organisation. This will help in access to the reserved area of Faith to Action website among other (Member only pages)

Name / Official title / Direct line / Email
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Type of organization: (Tick where applicable)

  1. Faith organisation
  2. Community foundation
  3. Health Associations
  4. Health Institutions
  5. Health Facilities
  6. Medicine supply organisations
  7. International/National NGO
  8. Donor Agency (Specify)
  9. Private Foundation
  10. Other (specify)______

If faith organisations please specify the faith, denomination, name of the faith

Registration details

Number of employees/congregation

Objectives of the organization

To help us improve our services to membership, kindly tell us why you want to join and what types of activities are of interest to you/your organisation?

What contribution will your organisation provide to the Network?

What are your expectations from the Network?

What services does your organization provide?

Does your organization give grants?

How did you learn about Faith to Action Network?

a)Mass media (Radio, TV, newspapers)______

b)Brochures______

c)Another organization (Please indicate the name of organization)______

d)An individual (Please indicate the name of the Individual)______

e)Website

f)Faith to Action Network Survey______

g)Other ( Specify)______

Note

  1. The Network’s Steering Council reserves the right to accept or reject the application for membership
  2. Please attach photocopies of registration documents and any other supporting documents i.e. brochure and recent annual report of the organisation

Membership fee

Membership to the Faith to Action Network is by annual subscription, payable at the beginning of the year. The membership subscription is an annual fee and is non-refundable once membership has been activated. The membership fees are divided into two categories:

  1. USD 100 for Local and National organisations
  2. USD 200 for Regional, International and Network organisations

Note: For the year 2014,membership fees have be waived!

I ______on behalf of my organization, agree to work in accordance with the above stipulated criteria.

Name of Organization______

Name and Signature______

Date and Official stamp______

FOR OFFICIAL USE ONLY

Application Received on: ______

Vetted by Steering Committee on: ______Approved on: ______

Membership Number______Membership Renewal Date: ______

Faith to Action Network | Hatheru Court (Lavington) Hatheru Road, Off Gitanga Road, P.O Box 2438-00100 Nairobi-Kenya

Tel: +254 20 203572302/ 20 736 616 491