CSEM Membership Request

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* 1. Please complete the following information for your organization:

Organization's Name *

Address 2 *

City/Town *

State/Province

ZIP/Postal Code

Country

Twitter Page *

Facebook Page

Website

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* 2. Please select the category type of your organization.

Non-Governmental

Governmental

Faith-Based

Academic

Other (please specify)

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* 3. Nominated UHC focal point for the CSEM TO CONTACT REGULARLY

Name

Title

Skype Name

Email Address

Phone Number

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* 4. What are your organization's priority areas in Universal Health Coverage (UHC)? Please select all that apply.

Ensure Political Leadership Beyond Health – Commit to achieve UHC for healthy lives and well-being for all at all stages, as a social contract.

Leave No One Behind – Pursue equity in access to quality health services with financial protection.

Regulate and Legislate – Create a strong, enabling regulatory and legal environment responsive to people’s needs.

Uphold Quality of Care – Build quality health systems that people and communities trust.

Invest More, Invest Better – Sustain public financing and harmonise health investments.

Move Together – Establish multi-stakeholder mechanisms for engaging the whole of society for a healthier world.

Address Gender Equality and Women's Rights - Acknowledge the importance of gender in realizing health for all.

Other (please specify)

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* 5. Why are you interested in joining the CSEM?

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* 6. ARMS/TOBACCO RELATED DISCLOSURE STATEMENT

My entity/organization/institution does not have or has had during the past four years any formal association, affiliation or link, with the tobacco or arms industry, or any subsidiary of a tobacco/arms company or commercial entity involved with the manufacture, sale, or distribution of tobacco/arms or tobacco related products. Formal association, affiliation or link with the tobacco or arms industry may include, but is not limited to:
a) consultancies or contractual/commercial relationships involving business (e.g. licensing, joint venture or research and development agreements) or other interests (e.g. advocacy or public relations)
b) the possession of a financial stake, e.g. shareholdings or bonds
c) a proprietary interest in a substance, technology or process (e.g. ownership of patent)
d) any programmes, initiatives, research, or projects, either independent or jointly administered which have been directly or indirectly endorsed, funded either monetarily or otherwise, or promoted by the tobacco/arms industry, a subsidiary of a tobacco/arms company or any commercial entity involved with manufacture, sale, or distribution of tobacco/arms or tobacco related products
e) financial interests, controlling interests (i.e. senior-level individuals, including executive board members, with current or previous affiliations, financial or otherwise, with the tobacco/arms industry.
I also understand that the CSEM Secretariat reserves the right to request additional information from my organization/institution in this regard.

DECLARATION. I hereby declare that the disclosed information is true and complete. Should there be any change to the above information, I will promptly notify the CSEM Secretariat of relevant changes.

I am requesting CSEM Membership as an individual so this does not apply to me.