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Online request for a consumer representative
Cancer Voices Australia provides a voice for people affected by cancer at the national level. We thank you for asking us to assist your organisation in recruiting informed consumer representatives for your specific, national level needs. To help us select the best nominee for you, please complete this electronic request form in as much detail as possible.
A. Number of representatives requested
*
B. Requesting organisation details
Name of organisation
*
Contact person
*
Position
*
Address
*
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Phone
Email
*
Website
C. Requesting consumer representative details
1. Representation type
Please tick the appropriate box or complete the Other section
Committee
Review Panel
Research project
Guideline development panel
Working group
Board
Other
2. Title of working group/research project/committee/panel or other
*
3. Membership composition
4. Project description/ Terms of reference
*
(in layman's terms please)
5. Experience or interests required of the consumer representative
Please outline full requirements (ie. cancer type/gender/geographical location)
6. Proposed commitment required from the consumer representative
Meeting duration
Meeting location
Time of meetings
AM
PM
Evening
Weekends
First/next meeting date
Meeting frequency
In person or via teleconference
In person
Via teleconference
7. Available subsidies for the consumer representative
We expect travel and other related costs to be met by your organisation. Please specify if subsidies are not available, and the expected costs likely to be incurred.
NOTE: It may take up to two weeks for the nomination and selection process to be completed, although we will aim for a speedier turn around.
Verification
Please enter any two digits
*
Example: 12
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