TBpeople membership application form Survey

Questions with an asterisk are mandatory
All data provided in the application is kept confidential

1.I would like to become a member of TBpeople Network. Hereby I confirm that:(Required.)

I have or had tuberculosis in the past

I haven't had tuberculosis, but my close ones -- friends or relatives -- have/had tuberculosis

I accept the vision, mission, and objectives of TBpeople

I accept terms of membership as described in the TBpeople Membership Regulations

PERSONAL INFORMATION

2.First name(Required.)

3.Surname(Required.)

4.Middle name

5.Gender(Required.)

6.Date of birth(Required.)

Day/month/year

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

7.Country of residence(Required.)

8.Town(Required.)

9.Valid email address (it has to be your own personal email address, not belonging to another person or an organization)(Required.)

10.Contact telephone number(Required.)

MOTIVATION

11.Please describe briefly why you are interested in becoming a member of TBpeople. If you are applying for associate membership, please write who of your close ones had TB and how it affected your life.(Required.)

Note: motivation does not affect the decision to whether or not accept you as member of TBpeople. It is important to us as it gives us the understanding of why you are interested in joining TBpeople.

Important: TBpeople is not just an organization, it is a community. That is why we ask our new members to introduce themselves in TBpeople mailing list.