Converge Application

Organisation:

*
( * indicates required)

Postal Address:

Suburb:

City:

Country:

New Zealand

Contact Person:

Position Held:

Phone Number:

- *

Other Phone:

Fax Number:

Return email address:

*
Where can we send email to you?
If you do not have any email address enter your name.

Preferred login:

*
short form of organisation name (up to 5 characters).

To qualify for Converge your organisation should be a member of at least one of the partner organisations. Please indicate membership below.

Member of:

Yes	No	ANGOA
Yes	No	Council for International Development
Yes	No	Environment and Conservation Organisation

If your organisation is not a member of ANGOA, CID or ECO then please tell us about your organisation and its activities so that your application may be considered.

Services:

Yes	No	Converge Web Site
Yes	No	<your-org>@converge.org.nz - email address
		Preferred email name, <your-org>, if different from login above.
Yes	No	Redirect email to existing email account
If yes, state email:

We agree to the Converge terms (previous page) *