UICC Membership Application Form

SECTION 1 - ORGANIZATION DETAILS

Type of Membership requested:
 Full /  Associate
Name of Organization:
English translation (if applicable):
Official postal address of organization:
Street
City
State / Region / Province
Zip / Postal Code
Country
Main telephone number(s): / Main Fax number(s):
General email(s): / Website address:
What is the working language of your organization?

SECTION 2 – ORGANIZATION PROFILE

Is the main part of your organization's work concerned with the fight against cancer?
 Yes /  No
Please provide a summary of your organization’s AIMS or MISSION STATEMENT
Please provide a summary of your ACTIVITIES in the following areas:
Cancer Awareness Campaigns
Cancer Prevention
Cancer Research & Publications
Education & Training
What are your organization’s other AREAS OF INTEREST / EXPERTISE?
In which year was your organization founded?
How many people work in your organization?
Staff: / Volunteers:
What are your organization's sources of income?
What is your organization’s annual revenue? (in local currency / USD equivalent)
What other international bodies is your organization member of?

SECTION 3 - GOVERNANCE

Is your organization under the authority of a government department?
 Yes /  No
If YES, please specify
Does your organization have a governing body?
 Yes /  No
If the answer is YES, what is the name of this governing body?
How many members does it have?
How many of its members have a medical degree or a scientific degree in a cancer-related discipline? Please list names.

SECTION 4 - YOUR MEMBERSHIP IN UICC

Has the organization been a UICC member in the past?
Where did you hear about UICC?
In which programmes, regions or projects would you like to PARTNER WITH UICC?
What are your expectations of UICC membership?

SECTION 5 - CONTACT INFORMATION

Designated UICC contacts:
Name / Direct email / Direct phone
MAIN UICC CONTACT
FINANCE CONTACT (Invoicing)
Key staff contacts:
Position / Name / Direct email / Direct phone
President
Chief Executive Officer / Executive Director
Chief Financial Officer / Financial Director
Communications Officer
Cancer Control / Programmes Officer
Cancer Control Policy Officer
Tobacco Control Officer
Other key staff:
Position / Name / Direct email / Direct phone

SECTION 6 - REFERENCES

Please list the names and addresses of three (3) organizations or individuals “involved in cancer control” we could contact for references (preferably at least one organization should be in your own country and, if possible, member of UICC).

Reference 1

Contact Name
Position
Organization
Address
City and Country
Telephone
Fax
Email
Relationship with reference

Reference 2

Contact Name
Position
Organization
Address
City and Country
Telephone
Fax
Email
Relationship with reference

Reference 3

Contact Name
Position
Organization
Address
City and Country
Telephone
Fax
Email
Relationship with reference

Please send the following documents

Attached / To Follow
Constitution 1
Annual Report 2
Financial Statement 3
Organization Chart

Your name: ………………………………………………………………………………………………………………………

Position in the organization: ……………………………………………………………………………………………

Phone: ……………………………………………………………………………………………………….…………………….

E-mail: …………………………………………………………………………………….……………………………………….

Date: …………………………………………………………………………………………………………………………………

Signature: …………………………………………………………………………………………………………………………

Notes

1. Constitution or any other document describing your governance structure.

2. Annual report or any other document describing your institution and its activities

in the past year.

3. Statement of annual income and expenditure for the past year.