Membership Application

MEMBERSHIP TYPE

Type of Membership (Circle relevant field): Ordinary/Affiliate

APPLICANT INFORMATION

Title (Circle relevant field): Prof/A/Prof/Dr/Mr/ Mrs/Mdm/Ms/ Other (Please State)

Name as per passport (please underline Last Name):
Preferred Name
Gender (Circle relevant field): M/ F
Nationality:
E-mail:
Phone (Office):
Phone (Mobile):
Please include country code

Please include country code

Institution or Affiliation:
Department:
Current Mailing Address:

Designation:

Country:
Discipline/Specialisation (Circle relevant field):
Clinical Specialist; Academic / Research / Advocate / Others (Please
state:____________________)

City:

CEVHAPS MISSON & GOALS

Mission
To reduce the significant health, social and economic burden of viral hepatitis in the Asia Pacific
region.
Goals
Advocate and support initiatives aiming to prevent transmission and increase access to
healthcare and support for all people living with viral hepatitis
Promote greater public awareness about viral hepatitis
Develop strong viral hepatitis policies and national strategies across Asia Pacific
SIGNATURE

I hereby declare that all the above information is true at the point of registration. In addition, I also
declare my support of CEVHAPs mission and goals to eradicate viral hepatitis in Asia-Pacific.
(For Affiliate Membership: On behalf of the organisation that I represent, I declare its support of
CEVHAPs mission and goals to eradicate viral hepatitis in Asia-Pacific.)
Signature of applicant:
Date:
RECOMMENDATION BY MEMBERSHIP DEVELOPMENT COMMITTEE (OFFICIAL USE ONLY)

APPROVAL (OFFICIAL USE ONLY)**

Approved/Rejected by (circle relevant field) :

Signature:

Date:

*Kindly please fill in all fields in block letters.

**Please note that your membership application is subjected to the approval of the Executive Committee based on the recommendation
of the Membership Development Committee. An email response regarding the outcome of your application will be sent to you within 21
working days.