USAID’s NTD Database, managed by ENVISION User Registration & Acknowledgement Form *Name (first, last): ________________________________ *Title: __________________________________________ *Organization: FHI-Asia HDI FHI-Africa IMA USAID – Washington CWW USAID – Mission MDP RTI ITI HKI WHO CRS Other (Please specify) ___________________ *Email: ___________________________________ Phone: _____________________________________________ *USAID-supported NTD Project(s) where applicable: ENVISION END in Africa END in Asia USAID-supported APOC Other USAID-supported mechanism *Country(/ies) you represent (if applicable): ___________________________________ ______________________________________________________________________ *Brief description of role on USAID-supported NTD project (if applicable): *Required My signature indicates my acknowledgement of the following regarding the use of data stored in USAID’s NTD database:
USAID’s NTD Database, managed by ENVISION User Registration & Acknowledgement Form *Name (first, last): ________________________________ *Title: __________________________________________ *Organization: FHI-Asia FHI-Africa USAID – Washington USAID – Mission RTI HKI CRS HDI IMA CWW MDP ITI WHO Other (Please specify) ___________________ *Email: ___________________________________ Phone: _____________________________________________ *USAID-supported NTD Project(s) where applicable: ENVISION END in Africa END in Asia USAID-supported APOC Other USAID-supported mechanism *Country(/ies) you represent (if applicable): ___________________________________ ______________________________________________________________________ *Brief description of role on USAID-supported NTD project (if applicable): *Required My signature indicates my acknowledgement of the following regarding the use of data stored in USAID’s NTD database: