Organizational Address *

Website URL *

City *

Post Code *

Country *—Please choose an option—AlgeriaAngolaBeninBotswanaBurkina FasoBurundiCabo VerdeCameroonCentral African RepublicChadComorosCongoCote d'IvoireDemocratic Republic of the CongoEquatorial GuineaEritreaEswatiniEthiopiaGabonGambiaGhanaGuineaGuinea-BissauKenyaLesothoLiberiaMadagascarMalawiMaliMauritaniaMauritiusMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSouth AfricaSouth SudanTogoUgandaUnited Republic of TanzaniaZambiaZimbabweAfghanistanBahrainDjiboutiEgyptIran (Islamic Republic of)IraqJordanKuwaitLebanonLibyaMoroccoOmanPakistanQatarSaudi ArabiaSomaliaSudanSyrian Arab RepublicTunisiaUnited Arab EmiratesYemenAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorth MacedoniaNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTaiwanTajikistanTurkeyTurkmenistanUkraineUnited Kingdom of Great Britain and Northern IrelandUzbekistanAntigua and BarbudaArgentinaBahamasBarbadosBelizeBolivia (Plurinational State of)BrazilCanadaChileColombiaCosta RicaCubaDominicaDominican RepublicEcuadorEl SalvadorGrenadaGuatemalaGuyanaHaitiHondurasJamaicaMexicoNicaraguaPanamaParaguayPeruSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSurinameTrinidad and TobagoUnited States of AmericaUruguayVenezuela (Bolivarian Republic of)BangladeshBhutanDemocratic People's Republic of KoreaIndiaIndonesiaMaldivesMyanmarNepalSri LankaThailandTimor-LesteAustraliaBrunei DarussalamCambodiaChinaCook IslandsFijiJapanKiribatiLao People's Democratic RepublicMalaysiaMarshall IslandsMicronesia (Federated States of)MongoliaNauruNew ZealandNiuePalauPapua New GuineaPhilippinesRepublic of KoreaSamoaSingaporeSolomon IslandsTongaTuvaluVanuatuViet Nam

Organizational Email Address *

Main Phone Number (With City and Country Code) *

Secondary Phone Number (With City and Country Code)*

Mobile Number (Whatsapp)(With City and Country Code)*

Name (Primary Contact) *

Designation *

Email *

Name (Secondary Contact) *

Designation *

Email *

In Which Language you would like to communicate with Us? *ArabicChineseEnglishFrenchSpanishOthers

Please provide at least the contact information of two different persons within your organization to avoid any lapse in communication.

Areas of Interest (Check all that apply) *Event and Conference ParticipationCapacity Building (Education and training, including fellowships, workshops, resources and publications, etc.)Advocacy (Disease area data, planning and policy, prevention and early detection, treatment and care, UN meetings, etc.)

Other Areas of Interest

What can WPA do for you?

Any other remarks?

I hereby confirm that the information contained in this application is true and correct to the best of my information and belief *
I agree