Membership Application Form

Part 1 – General Information

Full organisation name:

Acronym (if applicable):

Official Address:

Postal code:

City:

Country:

Tel:

Fax:

E-mail(s)	:

Website	:

VAT Number (if applicable):

EPHA Contact person:

Title:

Address:

Postal code:

City:

Country:

Tel:	Fax:

E-mail(s):

Hereby applies to become EPHA member.

There are two kinds of memberships at EPHA:

Full members are non-governmental organisations (NGOs) active in the public health sector and have two votes at the Annual General Meeting. (EPHA Statutes, Art.6)

Associate members are other not for profit organisations and professional bodies and are entitled to one vote at the General Assembly. (EPHA Statutes, Art.6)

EPHA’s Board will establish which kind of membership will be granted to your organisation by reading your statutes and part 3 of this application form.

Membership Fees

As a member of EPHA one of your contributions will be an annual membership fee that will be invoiced for payment at the beginning of each calendar year. EPHA membership fees are charged according to the annual turnover of your organization.

For 2016 the membership fees are levied according to the current bands of annual turnover:

Annual income	EPHA membership fees 2016
1)Over 1,000,000 Euros	5,000 Euros
2) 300,000 – 1,000,000 Euros	1,500 Euros
3) 150,000 - 300,000 –Euros	800 Euros
4) 50,000 - 150,000 Euros	400 Euros
5) under EUR 50,000	50 Euros

EPHA promotes and protects the health interests of all people living in Europe, and champions their involvement in decision-making related to their health. EPHA achieves its mission by strengthening dialogues between the EU institutions, citizens and NGOs in support of public health policies.

In applying for EPHA membership, our organisation agrees to abide by the Statutes and Bylaws, and commits to share the aims and objectives of EPHA. We also commit to respect the confidentiality of information shared at EPHA meetings and through other mechanisms.

Date:

Signature	:

Printed Name	:

Position	:

Signature	:

Printed Name	:

Chairperson	:

Part 2 – EPHA special interest groups

Please indicate your organisation’s area(s) of primary focus and expertise by putting a cross beside the following areas:

Primary Focus	Area of Expertise
Advocacy – Research – Service Provision	◌	◌
Population health
Non-communicable diseases (please specify):	◌	◌
Food & nutrition	◌	◌
Addictive substances	◌	◌
Mental health	◌	◌
Environment	◌	◌
Sexual & reproductive health	◌	◌
Health sector
Workforce	◌	◌
eHealth	◌	◌
Pharmaceuticals & medical devices	◌	◌
Communicable diseases (please specify):	◌	◌
Health services	◌	◌
Non-conventional medicine	◌	◌
Patient Rights	◌	◌
Cross cutting inequalities
Global health	◌	◌
Children	◌	◌
Adolescents	◌	◌
Gender	◌	◌
Migrants	◌	◌
Older Persons	◌	◌
Other groups (please specify)	◌	◌
Other Areas of Research / Expertise
(please specify):

Part 3 – Membership questionnaire

1. When was your organisation established?
2. In what country is it registered?
3. How would you describe your organisation? (Fill In as many as are appropriate)
◌ Non-governmental organisation ◌ Not-for-profit/charity ◌ Local or regional authority ◌ Educational/academic institution ◌ Professional Network ◌ Other:
3a. Are you a membership organisation? Yes ◌ No ◌
3b. What are your categories of membership (individuals, organisations, academics, etc.)? Please describe.
3c. How many members do you have in each category?
4. What is your organisation’s mission?
5. What are your organisation’s main strategic aims?
6. What are your organisation’s main activities?
7a. Who appoints the governing body in your organisation?
7b. What is the main policy making body in your organisation?
7c How is your organisation organised and run on a day-to-day basis?
7d. How many employed staff does you organisation have?
8. What are your organisation’s major publications?
(Newsletters, bulletins, position papers, electronic materials, etc)
9. Is your organisation itself a member of other organisations? If yes, which one(s)?
10a. What is your current annual budget? Gross Income – Expenditure
10b. How are you funded?
10c. Breakdown of income (amount and %):
- Private grants (foundations)
- EU or other publicly sourced grants
- Private donations
- Membership fees
- Project funding
- Commercial funds (companies) Please specify if grants or commercial transactions.
- Other sources of income (please specify)
10d. Please share with us the last year full financial report of your organization
10e. Please indicate how your organisation maintains independence from any grants received from industry or commercial organisations, if relevant.
(If your organisation has a policy document on conflict of interests please enclose a copy)
11. What do you consider will be the benefits to your organisation of membership of EPHA?
12. What perspective, representation and expertise does your organisation bring to EPHA?
13. Further comments

I enclose the following supporting documents / web links:

a copy of the statutes (description of the legal basis of your organisation or equivalent)

a copy of the latest annual accounts

any other relevant documents ( e.g., conflict of interest policy)

Please fill out this form, include all the supporting documents, and return it to the following address (by e-mail or regular post):

EPHA Secretariat

49-51 rue de Trèves – Boite 6 – B-1040 Brussels

Tel: +32 2 230 30 56 Fax: +32 2 233 38 80

E-mail: chris@epha.org

Web site: www.epha.org