CRB Membership Registration Form

Membership of CBR Africa Network (CAN)

Fill out the form carefully for Membership registration
Title

MrMrsMissDoctorOther
Full Name

First NameLast Name
E-mail
What is your current job title?
What is your organisation name?
What is your organisation's general email address? (If same as above leave blank)
What is your telephone number (including country code)
What is your organisation's postal address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your organisation's website
Which area(s) of the CBR Matrix are you working in? (tick all relevant)

HealthEducationLivelihoodSocialEmpowermentOther
. Your organisation's mission (mission statement or a sentence describing your work)
What is your organisation type? Tick the one most relevant.

CBR ProgrammeGovernmentNon-Government OrganisationInternational Non-Government OrganisationInternational OrganisationDisabled Peoples OrganisationTraining organisationDonor organisationStudentConsultant / IndividualOther
We need to know where to locate you in the CAN Directory. Is your work within a region of your country, or national, or do you work in more than one country of Africa?

Work in one or more regions of the countryNationalWork in more than 1 country of AfricaOther
If more than one country please tick the region(s) your organisation is working in below:

North AfricaEast AfricaWest AfricaCentral AfricaSouthern Africa
Thank you very much for completing this registration form. May we contact you if we need more information?

Yes I'd be delighted!No thank you!
Should be Empty:

Membership of CBR Africa Network (CAN)