IAPB Membership Form (Groups A – C)

MEMBERSHIP APPPLICATION FORM

(Non–Governmental Organisations (NGOs),

Ophthalmological Societies, Institutions, Hospitals, etc)

Enclose supporting information:

-Latest Annual Report

-Programme activities and annual budget

-Partners, if any

-Countries in which you have programmes

NAME OF THE ORGANISATION
ADDRESS
COUNTRY
E-MAIL / WEBSITE
REPRESENTATIVE TO IAPB [ATTEND IAPB MEETINGS / AGM & REGISTRATION WITH CHARITIES COMMISSION]
REP. NAME (DR. / PROF. / MR. / MS./____)
First Name / Last Name
POSITION / E-MAIL
PHONE / FAX
Country Code + Area Code + Phone No. / Country Code + Area Code + FaxNo.
ASSISTANT / OTHER CONTACTS (DR. / PROF. / MR. / MS./____)
POSITION / E-MAIL
CONTACT PERSON TO BE RELEASED PUBLICLY (e.g. ON IAPB WEBSITE) [IF DIFFERENT FROM ABOVE]
NAME (DR. / PROF. / MR. / MS./____)
First Name / Last Name
POSITION / E-MAIL
PHONE / FAX
Country Code + Area Code + Phone No. / Country Code + Area Code + FaxNo.
FINANCE/ACCOUNTS CONTACT [FOR PAYMENT OF MEMBERSHIP FEES]
NAME (DR. / PROF. / MR. / MS./____)
First Name / Last Name
POSITION / E-MAIL
PHONE / FAX
Country Code + Area Code + Phone No. / Country Code + Area Code + FaxNo.
ORGANISATIONAL PROFILE (State briefly the mission and objectives)

LIST COUNTRIES WHERE YOU HAVE PREVENTION OF BLINDNESS ACTIVITIES AND THE NATURE OF ACTIVITIES IN EACH COUNTRY (add separate sheet if necessary)

NO. / COUNTRY / NATURE OF ACTIVITY / PERIOD
1.
2.
3.
4.
5.

(Check relevant boxes)

VISION 2020: THE RIGHT TO SIGHT PRIORITIES COVERED BY YOUR ORGANISATION

CataractChildhood Blindness

TrachomaRefractive Error & Low Vision

OnchocerciasisOther (Specify regional priorities) ______

AREAS WHERE YOU CAN CONTRIBUTE TO PROMOTE VISION 2020: THE RIGHT TO SIGHT

Disease ControlResearch

Human Resource DevelopmentFinances

Infrastructure DevelopmentAny other(Specify) ______

MEMBERSHIP CATEGORY & ANNUAL FEES FOR 2012(annexed to 3% annual increase)

Group AUS$ 60,100

Group BUS$ 17,485

Group CUS$ 1,640

We will be happy to promote IAPB and VISION 2020: The Right to Sight and participate in joint promotional and programme activities together with other members and partners. We also agree that IAPB has the right to use information in this application form in websites and any other promotional materials.

Signature:______Date:______

Name:______Organisation: ______

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