C4D Service Providers Institutional Member Application Form

About Your Institution

Name of Institution (required)

Website (required)

Country (required)
---AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Town or City (required)

In what capacity do you wish to apply as an institution? (required)
---Non-Profit OrganisationMedia InstitutionUniversity / Training InstitutionPrivate Sector OrganisationPublic Sector OrganisationOther (please provide details below)

If other, provide details here.

About You

(Person Officially Responsible for this Application)

First Name (required)

Last Name (required)

Already an Individual Member? (required)
YesNo

Contact Email (required)

Contact Telephone Number (required)

What is your role in the instution? (required)

Any other information (please provide below if applicable)

How would you briefly describe your institution?
(Please use wording that you would like to have on the C4D Network site as your Institution’s Profile).

What is your institution's engagement / interest in C4D to date?

Which Institutional Subscription package do you wish to apply for? (required)
(Range based on size of organisation and type).
NB: 50% discount for those with HQ in Developing Countries - OECD classification.
---Subscription for small-scale institutions: $180.00Subscription for universities: $450.00Subscription for medium-scale institutions: $450.00 (with 10+ staff)Subscription for largescale institutions: $900.00 (with 100+ staff)

Please can you nominate a person to be your Focal Point

This person will then be the administrative focal point for the Network - confirming new members associated with the Institutional subscription, ensuring the Institutional Profile is kept up to date etc).

Focal Point Full Name (required)

Already an Individual Network Member? (required)
YesNo

Contact Email (required)

Contact Telephone Number (required)

What is their role in the Institution? (required)

Any other information (please provide below if applicable)

Please can you identify initial persons to be joined as Members of the C4D Network under your Institutional subscription.
(further names can always be added on an on-going basis as well).

Please submit in this format:
Person 1: First Name Last Name. Email Address.
Person 2: First Name Last Name. Email Address.

Please use this section to add any comments, questions or further information, thank you.