Your Job Title

Your name:

Your job title:

Your e-mail:

Your organisation’s name:

Your organisation’s address:

Your organisation’s phone number:

Brief description of what your organisation does:

Generic e-mail for your organisation (in case of changeover of staff etc):

The WTCA meets 3 times a year. How much involvement can yourself and/or your organisation have with the group?:

I will attend most meetings or dial in YES / NO

I cannot attend most meetings or dial in* YES / NO

* Your organisation can be a member without having to attend meetings but any terms agreed with regards to sign-up apply the same for example, logos on media releases.

By signing up to the WTCA, you’re agreeing to:

·  Receive e-mails in relation to our work

·  Use of your organisation’s logo on any WTCA related literature including any web or print media

·  Your organisations name, as part of the WTCA, being used in correspondence with AMs and MPs with regards to tobacco control matters

·  Ensure that your organisation has approved your participation on the WTCA and by proxy your agreeance to proposed outputs by proxy

All correspondence will be sent to members prior to being sent wider for collaborative agreeance. Members will have 48 hours to send any amendments or to withdraw their name from a piece of correspondence if they so wish. This will not impact on your membership.

Name:

Date:

Neither I nor my organisation has connections, affiliations or holdings with the tobacco industry or its representatives* YES / NO

*Some organisations maintain connections to tobacco companies for the purposes of monitoring, for example, some tobacco policy organisations own one share in tobacco companies in order to receive the annual report and attend AGMs. These organisations would still be eligible for membership. Please declare this.

When completed, please return this form to:

About Wales Tobacco Control Alliance

The Wales Tobacco Control Alliance (WTCA) is an action group, coordinated by us, which aimsto enable all third sector and professional organisations involved with tackling tobacco in Wales to inform and influence policy development and implementation, at both a UK and Wales level.

The WTCA works to monitor the Welsh Government's Tobacco Control Action Plan which was created in February 2012 and will run until 2017. The aim of this Plan is toreduce the harm caused by tobacco use more generally across Wales, with the key focus around acomprehensive strategy containing ambitions to reduce adult smoking prevalence to 16% by 2020.

Principles of the WTCA

·  Membership will reflect the wide range of third sector and professional body organisations and disciplines concerned with the impact of tobacco on Wales and its people

·  The WTCA will endeavour to address tobacco inequalities in all its activities

·  The WTCA will be an inclusive, participatory body that encourages active engagement of its members

·  The WTCA will be transparent and accessible, and will consult with its member organisation on proposed actions

Who can join?

·  Membership is open to all third sector and professional body organisations in Wales whose remit includes a tobacco control focus or who work with those vulnerable to tobacco use

·  All member organisations are required to declare that they do not haveconnections, affiliations or holdings with the tobacco industry or its representatives

·  Individuals are not eligible to join the WTCA, although they are eligible to join the Wales Tobacco or Health Network

·  Organisations must ensure delegates to the WTCA are sufficiently senior and knowledgeable to vote on coordinated policy initiatives of the WTCA

Contact

Emily Cole – Digital Communications and PR –