We invite you to become part of the CBR Africa Network (CAN

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We invite you to become part of the CBR Africa Network (CAN Powered By Docstoc
					                 CBR AFRICA NETWORK SURVEY FORM
As part of its information sharing mandate, CAN is collecting information on CBR programmes in Africa. Kindly fill in
               the form and forward it to info@afri-can.org. Visit www.afri-can.org to know more about us.



1. Date: _____________


2. Name of Organization/CBR Programme : ___________________________________________



3. When was your Organization/Programme Established? ________________________________



4. Type of Organization (Indicate relevant option eg. a) b) c) d))…………………………………………………
a) Disabled Persons Organization    b) Non Governmental Organization c) Training Institutions d) Community Based Organizations

e) others



5. CBR Programme coverage
           Indicate Area covered(e.g. countries, districts, provinces, etc) ___________________________________

           Number of persons with disability benefitting from CBR programme_____________________________________________



6. Objectives/Activities of the CBR programme: -


____________________________________________________________________________________________________________



____________________________________________________________________________________________________________



____________________________________________________________________________________________________________



____________________________________________________________________________________________________________




7. Affiliated/Sponsoring Organization(s)_______________________________________________________________


   ________________________________________________________________________________________________________




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              CBR AFRICA NETWORK SURVEY FORM
As part of its information sharing mandate, CAN is collecting information on CBR programmes in Africa. Kindly fill in
               the form and forward it to info@afri-can.org. Visit www.afri-can.org to know more about us.



8. Organization’s Official Contact Information:-


Physical Address :- _______________________________________________________________________________________


Official email address:- ________________________________________ Website        ________________________________



Telephone:- ____________________________________________ Postal Address          _________________________________



9. Organization’s Main Contact Person’s Information:-


Name: - ___________________________________________________


Email address:- ____________________________________________ Telephone:- ________________________________




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posted:9/17/2012
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