Becoming a Forum Member Application form to become a forum member Complete the following form below. Name of Organisation* Address* Postal Address if different from Above: Phone: E-mail: President: Treasurer: Secretary: Administrator: Is your local organisation an Incorporated Society / Trust (Select one): YesNo Does your organisation have a National Body: YesNo Is your local organisation registered for GSTYesNo If Yes, please provide GST number Has your local organisation received funding from the MoH in the past?* YesNo Please provide details given below Number of members in your local organisation: Number of Staff Full Time: Number of Staff Part Time: Number of Staff Volunteer: How many paid staff do you have: Position: Full TimePart Time Position: Full TimePart Time Position: Full TimePart Time Position: Full TimePart Time How does your organisation conform as a not for profit organisation and give details of your primary focus of working with people with a disability?* As part of your group’s application to become a forum member the Trust (trustees & forum groups) invite you to attend a Trust meeting to tell the Trust about your organisation and to answer any questions that Forum Members may have. Are you prepared to attend a Trust meeting for this purpose? YesNo As a Forum Member Group, you are expected to participate in Forum activities. This includes attendance at quarterly Forum meetings. Is your organisation prepared to make this commitment? YesNo What is the name of the person that will represent your organisation at these meetings? Name of Forum Group Representative As a part of the monitoring requirements of the Ministry of Health, the WBoP Disability Support Trust surveys the members of Forum Groups on an annual basis. Is your organisation prepared to support and undertake this task? YesNo The wishes to become a member of the Western Bay of Plenty Disability Support Trust. Name of Applicant: Date: Please tick here to confirm Name of Witness: Date: Please tick here to confirm The above information may be shared with other existing forum group members. Please attach any other relevant information and return your completed form to the Coordinator at WBoP Disability Support Trust, P O Box 15466, Tauranga 3144 or email email@example.com (Relevant information could be for example, a copy of your strategic plan, business plan and annual accounts/auditors report). Thank you for your interest in joining the forum.