Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. ETHF Membership Application Form Thank you for your interest in becoming a member of East Timor Hearts Fund. For details on membership, including eligibility criteria please click hereIf you have any questions please contact info@easttimorhearts.org.au OK Question Title * Contact DetailsTitle Prof Dr Mr Ms Mrs Miss OK Question Title * First name OK Question Title * Surname OK Question Title * Email OK Question Title * Phone OK Question Title * Current full address OK Question Title * Country OK Question Title * Occupation OK Question Title * Current employer OK Question Title * Are you a Timorese National? Yes No OK Question Title * Membership applicationWhat type of membership are you applying for? Individual Organisation OK Question Title * What is your connection to East Timor Hearts Fund? Volunteer Donor Partner organisation Other Other (please specify organisation) OK Question Title * Please describe how you have demonstrated support for ETHF over the last two years. OK Question Title * What is your connection / interest in heart health? OK Question Title * What is your connection / interest in Timor-Leste? OK Question Title * Please provide referee contact details. You can provide details for either:a) Two individuals who are not members; orb) One individual who is a current member of ETHF OK Question Title * AttestationBy completing this membership application you agree to:(1) support the Objects of ETHF as defined in the ETHF constitution; (2) abide by the values of ETHF; and (3) uphold the duties of a Member as set out in the ETHF Membership Regulation, (4) at all times for the duration of your Membership (if approved). I agree to all of the above OK SUBMIT
