TB Proof Member Application Form
Dear prospective TB Proof member, please read the TB Proof Core Group Membership Terms of Reference before completing this application form (sent attached with email).

If you have any issues or queries, please do not hesitate to contact Wieda, TB Proof's communications' officer via email: wieda@tbproof.org.

Thank you for taking the time to complete this form!
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Email *
Name and Surname *
Age
Clear selection
What is your birth date? *
MM
/
DD
/
YYYY
Gender *
Are you a TB survivor? *
If yes, what type of TB?
Clear selection
Please provide your contact number:
Town, country you are based in: *
Briefly tell us what line of work you are in. *
How did you discover TB Proof? (you can check more than one box)
Would you like to be a Core Group or Wider Group member (details as per Terms of Reference)
Clear selection
If you have selected to be a Core Group Member please write a short paragraph regarding your personal experiences and interest regarding Tuberculosis.
How would you like to contribute your time as a member? *
Required
Which aspects would you like to be involved in? (sometimes these overlap): *
Required
We'd love to know about any skills and knowledge that may be valuable in helping to #EndTB. Examples: business or organizational skills, communication skills, speaking skills, computer literacy, skills/experience in advocacy, education, research, politics, legal field, community projects, marketing, fundraising, etc (or knowing people who do), connections with community workers.
How much time are you generally able to contribute? *
Which of the following TB Proof communication channels would you prefer to be included in? *
Required
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