Defy Consortium — Expression of Interest Form

Defy Consortium — Expression of Interest Form

Submit this form to express your organisation’s interest in joining the Defy Consortium.
Organisation Information
Company Name
HQ Country
Operating Markets
Company Website
Type of Organisation
Industry / Sector
Other (Please specify)
Primary Contact
Name

First NameLast Name
Email
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Job Title / Designation
Preferred Mode of Contact
Membership Type
Membership Type (Expression of Interest)
Areas of Interest & Motivation
Areas your organisation wants to support
Other (Please Specify)
Which underserved groups do you aim to support?
Other (Please Specify)
Why is your organisation interested in joining the Defy Consortium?
What resources or capabilities can your organisation contribute? (e.g., technology, data, field networks, funding, talent, user communities)
Consent & Declaration
- I confirm the information provided is accurate.
- I acknowledge that submitting this form does not guarantee membership.
- I agree that Defy Consortium may contact me for follow-up discussions.
- I agree to the processing of my data according to the Privacy & Data Protection.
Date of Submission

MonthDayYear
Signature
Type a question
Should be Empty: