Please, tick all that applies:
MANDATORY FIELDS ARE MARKED WITH AN ASTERISK*
I represent a (please, choose the one that applies)*:
national cancer patient umbrella organisationcancer patient organisationa groupmyself on individual basisother - please specify
My organization is: not-for-profitfor profit
Details of the legal representative of your organisation (or of the individual)
First and last name*
Position of this person in your organization (if applicable)
Email address of this person*
Phone number*
Address*:
Zip code*:
City*:
Country*:
The geographical basis for my/our work is*: local (my city, my county or province)nationalinternational
The main purpose of the applicant is*:
the promotion of the interests of cancer patientsthe provision of support or other services to cancer patients and/or their caregiversthe support of all patients among which, cancer patientsthe development of advocacy for people in need among which, cancer patientsother
If you chose "other", please specify:
The applicant is an organisation already member of/affiliated with A NATIONAL umbrella org:
NoYes
If yes, please provide the name:
Does the applicant work or have any commercial interest in companies active in the diagnostic or treatment of cancer (such as, but not limited to pharmaceutical companies, diagnostics, or nutrition companies)?
yesno
PLEASE FILL IN THE FOLLOWING DETAILS OF THE ORGANISATION (if applicable)
Organisation Name (in English)
Organisation name (in the original national language)
Acronym/abbreviation (e.g., CPE)
General email address
Telephone number with country code
DETAILS OF THE PERSON REPRESENTING YOUR ORGANISATION IN CPE (if different from the legal representative)
First and last name
Position of this person in your organization
Email address of this person
Direct phone number (if possible)