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* 1. Please complete the following information for your organization:

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* 2. Please select the category type of your organization.

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* 3. Nominated UHC focal point for the CSEM TO CONTACT REGULARLY

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* 4. What are your organization's priority areas in Universal Health Coverage (UHC)? Please select all that apply.

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* 5. Why are you interested in joining the CSEM?

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* 6. ARMS/TOBACCO RELATED DISCLOSURE STATEMENT

My entity/organization/institution does not have or has had during the past four years any formal association, affiliation or link, with the tobacco or arms industry, or any subsidiary of a tobacco/arms company or commercial entity involved with the manufacture, sale, or distribution of tobacco/armsĀ or tobacco related products. Formal association, affiliation or link with the tobacco or arms industry may include, but is not limited to:
a) consultancies or contractual/commercial relationships involving business (e.g. licensing, joint venture or research and development agreements) or other interests (e.g. advocacy or public relations)
b) the possession of a financial stake, e.g. shareholdings or bonds
c) a proprietary interest in a substance, technology or process (e.g. ownership of patent)
d) any programmes, initiatives, research, or projects, either independent or jointly administered which have been directly or indirectly endorsed, funded either monetarily or otherwise, or promoted by the tobacco/arms industry, a subsidiary of a tobacco/arms company or any commercial entity involved with manufacture, sale, or distribution of tobacco/arms or tobacco related products
e) financial interests, controlling interests (i.e. senior-level individuals, including executive board members, with current or previous affiliations, financial or otherwise, with the tobacco/arms industry.
I also understand that the CSEM Secretariat reserves the right to request additional information from my organization/institution in this regard.

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