AFLA
Application Form for AFLA Affiliation
This form is to be completed only by Executive Director/ Board Chair of the Life Giving Center
Communication Data
The application fee is Free annual subscription is US$ 20.00.
Ministry Name
Short Name
Address: Street / No.
Mailing Address: Street / No.
Address: ZIP-Code / City
Mailing Address: ZIP-Code / City
Address: Country (State)
Mailing Address: Country (State)
E-Mail
Web address
Telephone
FAX
Date of Foundation (Day / Month / Year)
Reason for foundation:
 Crisis Pregnancy Centre
Founded by (name and address of person / association)
Foundation
 Maternity home
 Post Abortion
 Place of Safety{Children’s or Aged home}
 Sexual Integrity
Affiliation
Status
 Others:
Kind of Centre:
Legal Status of Centre:
 Registered as a Company

Religious organisation
 Registered NGO / Society

non-profit Organisation
 Branch of a Local Church / Other :

Independent

Others:
 Centre was formerly affiliated with (Name, Address of organisation):
Until:
 Centre is presently affiliated with (Name, Address of organisation):
Since:
Po box 22696, Kitwe, Zambia
www.afla.in
AFLA
 Centre is affiliated with …………………………………………………………… (Name, Address):
Form of Centre government:
Since:
Number of Directors:
Number of Branches :
Average number of Staff:
Structure
Name and Address of Executive Director, Directors and Centre Officers:
For Official Use Only:
Date Received:............................................................
Action taken:...............................................................
Status: Affiliate or Non Affiliate
Annual Subscription Paid: Tick every year paid x
2013.................
2014................
2015...............
2016...............
2017...............
2018...............
2019...............
2020...............
Po box 22696, Kitwe, Zambia
www.afla.in