Supporter Application: Individuals

SUPPORTER APPLICATION FORM: Individuals

For completion by Individuals applying to become Supporters with the CLCI.

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.

Title

Name

First

Last

Position:

Address:

Direct Email Address: (if possible)

Direct Telephone: (if possible)

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

Why would you like to become a Supporter with the CLCI? How did you hear about CLCI? What do you hope to gain/give from collaborating with the CLCI?

Please provide a brief profile for use on our CLCI website collaborators’ section (approx. 100 words)

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

If you are human, leave this field blank.