FCTC Shadow Reporting Bursary Form for Civil Society Organizations

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April 2023

Email *

Full Name *

Title *

Organization *

Address *

City *

Region *

Postal Code *

Country *

Telephone (include country code) *

I confirm that my organization is part of the GATC Community (Member, Associate, or Network Participant), OR has a GATC membership application in process, OR was a former FCA member in good standing as of 2022. NOTE: THIS IS NO LONGER A MANDATORY REQUIREMENT. *

Yes

I confirm that I/the organization that I represent do not/does not have and have not/has not had any affiliation, direct or indirect, financial or non-financial, with the tobacco industry or with any organizations that receive tobacco industry funding. *

YES, I confirm that my organization DOES NOT have a tobacco industry affiliation as described above.

NO, I confirm that my organization HAS a tobacco industry affiliation as described above.

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