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Thanks for deciding to support our project.
Membership No (If known):
Title
First Name
*
Last Name
*
Organisation website (if available)
Position in organisation
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Phone
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Date of Birth
Email
*
Organisation
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First name (contact person 2)
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Last name (contact person 2)
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Position in organisation (contact person 2)
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Phone number (contact person 2)
Email (contact person 2)
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Address
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I would like to gift a membership to someone
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Type of organisation - choose one
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Academic Unit/School/Department
Charitable trust
Iwi organisation
Non-governmental, not-for-profit organisation
Not-for-profit community-based organisation
Professional association
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Organisational engagement with health (choose one)
*
Health is central to the work of the organisation
Health is not part of the work of the organisation but we are interested in health and prevention generally
Health is part of the work of the organisation
Areas of prevention
Determinants of Health
Public Health Infrastructure
Tobacco
Unhealthy Food
Alcohol
Are there particular ways that you could contribute to the work of the Coalition?
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Do you or have you had in the last 5 years any financial interests in commercial entities related to tobacco, alcohol or food?
*
No
Yes
If yes, please describe the nature of the relationship, or if no, please note N/A
*
Membership Type
2-5 FTE - $300.00
6-20 FTE - $1,000.00
More than 20 FTE - $3,000.00
Income $30,000 to $50,000 - $30.00
Income $50,000 to $75,000 - $50.00
Income $75,000 to $100,000 - $100.00
Income $100,000 to $120,000 - $150.00
Income above $120,000 - $200.00
I am renewing my membership
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Membership:
NZD
I would also like to include a donation:
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Total:
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I acknowledge and accept the terms and conditions of membership
View Terms and Conditions
I acknowledge and accept the terms and conditions of membership
View Terms and Conditions
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Just a few last questions
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Yes
No
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First name
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Email
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