Membership Application: Organisations - Coalition for Life Course Immunisation (CLCI)

Please fill out the following form if you are applying as an organisation.

We will confirm receiving your application within 1 week. Following receipt of the application, you will be contacted by the CLCI General Secretary to discuss your membership. Your application will be sent to the CLCI Trustees and we will contact you again within 21 days.

If you are a registered charity - we will request proof of registration and a high-resolution version of your charity logo, so that we can display it on our website .

Organisational Details

Organisation Name: (in English)

Organisation Name: (in your language)

Acronym: (e.g. EFCCA)

Organisation Address:

Year Established:

Charity Number: (if applicable)

Number of Staff:

Number of Volunteers:

Number of beneficiaries: (or members if applicable)

General Email Address:

Website/URL

Telephone Number: (with country code)

LinkedIn Page:

Twitter Page:

Why would your organisation like to become a member of CLCI? (Please include what benefit you see in membership to your organisation)

About your organisation: (Please let us know in detail about the work of your organisation)

Please include a profile you would like displayed on our website (approx. 100 words). Your profile should explain how your work impacts on vaccine uptake and advocacy.

Details of your representative

Title

Name

First

Last

Position:

Direct Email Address: (if possible)

Direct Telephone: (if possible)

Link to personal LinkedIn profile: (this is to enable CLCI to connect with you)

I confirm that the information above is accurate, and that my organisation is eligible to be an organisational Member (as defined above) and is committed to working to further the objects of the CLCI and in particular to increase vaccine uptake and advocacy across the life course.