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. NB: In the case of organisations, this form should be filled by the contact person (or her/his designate) in charge of NCD activities. Please provide the information below to help us create an index of stakeholders in the country. BACKGROUND INFORMATION Name of your organization Your Full Names Field of Work (e.g. Health, Energy, Transport, Education etc). Designation or Title/Job Area of Expertise Mailing or Physical Address E-mail Address Telephone Number Cell phone Number Fax Number Website: How would you like to contribute to the NCD agenda in Kenya? Any comments or relevant information Are you the contact person? I would like to subscribe to NCD Alliance-Kenya mailing list Application fee ( 2000 5000 N/A) [ ] Yes [ ] No

[ ] Yes [ ] No [ ] Individual [ ] Organisation/Institution

Please mail the filled form to: info.nak@aihdint.org; ncdak@aihdint.org or have it delivered to the address below. You can now subscribe to periodic updates.

NCDA-K is housed at the African Institute for Health and Development (AIHD), 7 th Floor Suite B, Commodore, Wood Avenue (Off Lenana Rd)/Kindaruma Road Junction, P.O. Box 45259 00100, Nairobi, Kenya. Tel: 254 (20) 387 33 85, Cell:0727 850 851; Email: ncdak@aihdint.org, View the NCDAK Website.

Kenya NCD Partners Directory

Registration Form Ver1 Rev 1 2013