GLOBALink Membership Application Form

Personal details
Gender Mandatory field
 Title Mandatory field
 First name Mandatory field
 Middle name
 Last name Mandatory field
Email address Mandatory field
 Birthday Mandatory field
MSN
 Skype
 In tobacco-control since (year)
Photo (JPG only)
Organisation
Name of the organisation Mandatory field
 Website
Position
 Department
Address
Street, floor, suite Mandatory field

 Post Office Box
 Zip Code
Country Mandatory field
State / Area Mandatory field
City Mandatory field
(choose a state first)
Telephone Mandatory field
 Direct telephone
 Mobile telephone
 Fax
Recommandations
To become Member of GLOBALink, you need to be identified as a Tobacco-Control Professional.
In order to trigger the application process, please list three known advocates who could recommend your Membership to the network (GLOBALink Members would be a plus).
Please give Full Name, Organization, Address, Tel, Fax and email.
First tobacco control Advocate (name, address, telephone) Mandatory field
 First tobacco control Advocate (email address) Mandatory field
Second tobacco control Advocate (name, address, telephone) Mandatory field
 Second tobacco control Advocate (email address) Mandatory field
Third tobacco control Advocate (name, address, telephone) Mandatory field
 Third tobacco control Advocate (email address) Mandatory field
Background
Curriculum Vitae ( )
Degrees in public health / tobacco control
Describe your activities in tobacco-control Mandatory field
Recent publications
Where did you hear about GLOBALink ?
Regular bulletins
GLOBALink Today
 Medical Journal Update
NIMI (English)
Submission
Please report this word in the following textbox:
(If the image is missing, please fax your application to +41228091810)
I agree to the terms & conditions of GLOBALink, and I hereby certify that I am in no way affiliated with the tobacco industry, either directly or indirectly, and furthermore certify that I do not envisage any future affiliation with the tobacco industry.