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NCD ALLIANCE KENYA REGISTRATION FORM Dear NCD Stakeholder, Registering at NCDA-K allows you to connect with other

actors in Kenya and globally. Application fee is KES. 2000/= for individuals and KES. 5000/= for institutions. As a member, you will be part of the national movement that aims to steer NCD action in the country from the grassroots to the national levels. Please provide the information below to help us create an index of stakeholders in the country. BACKGROUND INFORMATION Your Full Names Name of your organization Field of Work Designation or Title/Job Area of Expertise Mailing or Physical Address E-mail Address Telephone Number Cell phone Number Fax Number How would you like to contribute to the NCD agenda in Kenya? Any comments or relevant information Are you the contact person? [ ] Yes [ ] No If NO above, who is the contact person? I would like to subscribe to NCD AllianceKenya mailing list [ ] Yes [ ] No Application fee ( 2000 5000 N/A) [ ] Individual [ ] Organisation/Institution Please mail the filled form to: info.nak@aihdint.org or have it delivered to the address below. Online registration form is available here: http://eepurl.com/r8Snf. Note that online registration will only be approved upon confirmation of payments.
NCDA-K is housed at the African Institute for Health and Development 2nd Floor Wood Avenue Court, Wood Avenue Off Lenana Rd, P.O. Box 45259 00100, Nairobi, Kenya. Tel: 254 (20) 387 33 85, Cell: 0727 850 851 Email: info.nak@aihdint.org Website: www.aihdint.org

Kenya NCD Partners Directory

Registration Form Ver1 Rev 1 2013