1. Personal Information
Full Name:*
Date of Birth:*Nationality:*Region:* – Select Region – Addis Ababa Afar Amhara Benishangul-Gumuz Dire Dawa Gambela Harari Oromia Sidama Somali Southern Nations, Nationalities & Peoples’ Region (SNNPR) South West Ethiopia Peoples’ Region Tigray Other… Other Region:City/Town:* – Select City/Town – Addis Ababa Adama (Nazret) Bahir Dar Gondar Dessie Jimma Hawassa Mekele Jijiga Harar Dire Dawa Gambela Assosa Dilla Semera Other… Other City/Town:Street Address:*Postal Code:*Phone Number:*Email Address:*
2. Organization Information
Organization Name:*
Position/Title:*Registration Number:*Registration Date:*Cannot be a future dateWebsite:Organization Region:* – Select Region – Addis Ababa Afar Amhara Benishangul-Gumuz Dire Dawa Gambela Harari Oromia Sidama Somali Southern Nations, Nationalities & Peoples’ Region (SNNPR) South West Ethiopia Peoples’ Region Tigray Other… Other Organization Region:Organization City/Town:* – Select City/Town – Addis Ababa Adama (Nazret) Bahir Dar Gondar Dessie Jimma Hawassa Mekele Jijiga Harar Dire Dawa Gambela Assosa Dilla Semera Other… Other Organization City/Town:Org Street Address:*Org Postal Code:*Organization Phone Number:*Organization Email Address:*
3. Interest in Joining the EHNCF Forum
Why do you want to join the EHNC Forum?*How can you or your organization contribute?*
4. Membership Type
5. Membership Fee (If applicable)
Membership Fee:
Payment Reference Number:
6. Terms and Conditions
Signature (Type Full Name):*Date:*Select today’s date or earlier
7. References (Optional)
Reference 1 Name:Reference 1 Contact Information:Reference 2 Name:Reference 2 Contact Information:
