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Online Membership Application

This form is to be used by any organisation that wishes to join the Asia Pacific Coalition on Male Sexual Health (APCOM) and works in the field of HIV among MSM or transgenders in any country or area of Asia Pacific. There is no cost to any organisation wishing to join.

Please fill in all fields accurately and include all details as requested. Once completed, you will submit the application automatically by selecting “Submit”. The organisation, the principal contact and the alternate contact will be emailed notice of the application. The principal contact person MUST RESPOND PROMPTLY to that email, following the instructions as given in the email, or the membership application will be cancelled. Your application information will be treated with complete confidentiality pending acceptance for membership.

Do not submit an incomplete form. If you have problems completing the form online, it is also available in a Microsoft™ Word ® version that you can request, complete and email or post to the APCOM Secretariat. You may also use the Contact Us form to request the APCOM Secretariat to email or post to you a hard copy of the application.

Organisation Name*

Description (briefly, what do you?)*

Street Address*

City, State/Province*

Country/Area*

Postal Address

Telephone (main office)*

Alternate Telephone

Fax

Email (for organisation)*

Web Site

For APCOM to assess your organisation for membership, we may need to contact others in your area, such as similar groups, donors or government officials. Please provide 2 references (name of contact, organisation, email and telephone number – for each).

Reference 1*

Reference 2*

What is the principal work of your organisation?

HIV Services (including prevention, treatment, care and support)?*

Yes No

MSM Targeted Services?*

Yes No

Advocacy work?*

Yes No

Research*

Yes No

Organisation Type*

Organisations applying for membership are assumed to want that the following information about the organisation be made publicly available: name of organisation, location (city, state/province) and organisation email address. ‘Publicly available’ shall include, but not be limited to, display on various pages in the public section of the website (e.g., the appropriate sub-region and/or country page) and upon requests to the APCOM Secretariat for referrals to organisations in a particular area.

Any organisation may request to have other information NOT be publicly available through the ‘opt-out’ function below. However, all information will be used and made available to all members, in the ‘members only’ sections for APCOM website, which require registration and password-protected entry.

If your organisation does NOT want the following information provided publicly as above, please change one or all of the below three items to “No”.

Share Address (street address made publicly available)*

Yes No

Share Telephone (telephone – main number - made publicly available)*

Yes No

Share Description*

Yes No

Contact Details

You need to provide details for two contacts within your organisation. These people will be responsible for receiving information from APCOM and distributing it within your organisation. They will also be responsible for performing some minimal administrative duties, such as voting for APCOM governing board representatives for your sub-region or area.

Principal Contact

Full Name*

Position*

Email*

Alt Email

Phone*

Alt Phone

Alternate Contact

Full Name*

Position*

Email*

Alt Email

Phone*

Alt Phone

After you submit the form, the organisation, the principal contact and the alternate contact will be emailed a notice of the application. The principal contact MUST RESPOND PROMPTLY to that email, following the instructions as given in the email, or the membership application will be cancelled. After APCOM receives a response from the principal contact, the application will be reviewed by the APCOM Secretariat. If there are no questions, you will be registered as a member and sent additional information within three working days.

Please note, by submitting this completed application, you are indicating that you understand the Privacy Statement on this website. In particular, you understand and agree that APCOM members cannot ‘opt-out’ of the use of any of the member organisation’s information from this application process in the limited-access, members only sections, even if you have asked that address, telephone and description not be made publicly available.