Organizational Membership Form

POTT Organisational Member Form

Name Of Organisation

Email

Phone Number

Website URL

Address

Legal Status

Incorporated - Limited Liability Incorporated - Not for Profit Unincorporated Members Organisation Cooperative Other:

Who does your organisation serve?

What are your organisations objectives?

What challenges, if any, are you experiencing in fulfilling your objectives?

Is there any specific healthcare project or initiative with which you would like assistance?

Yes No

If yes, please share your timeline

Within 0 - 3 months Within 3 - 6 months Within 6 - 12 months Other:

Do you agree to adhere to all of our N.I.C.E values? Non-Political | Inclusive | Collaborative | Empathetic?

Yes No

If No, please indicate what you do not agree to, and why?