Thank you for your interest in becoming a member of the Global Coalition Against Childhood Pneumonia. Please fill out the brief survey below to provide more information on your organization. After survey submission, we will contact you with more information on the Coalition's efforts and ways to get involved.

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* 1. Name

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* 2. Organization

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* 3. Country

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* 4. Phone

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* 5. Website

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* 6. Email

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* 7. Twitter

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* 8. Facebook Page Name

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* 9. Additional Online Platform Information

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* 10. Communications Contact (if different than above)

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