Membership Application Form - Cancer Patients Europe

Thank you for your interest in becoming a member of CPE!

Any not-for-profit organisations, groups, or individuals working for the benefit of cancer patients, wishing to become a member of the association shall address their request to the CPE Board by filling in the following form.

The benefits, rights, and obligations of membership are set forth in the articles of association you can access here.

There are two types of membership:

– FULL MEMBER: they have voting rights at the general assembly. They can be national cancer patient umbrella organisation based in geographical Europe or cancer patients organisations with specific features (article 5.1 of the Statute).

– ASSOCIATE MEMBER: they do not have voting rights at the general assembly. They can be cancer patients organisation not included in the previous case, groups or individuals (article 5.2 of the Statute).

Please refer also to article 5.3 of the Statute for further definitions.

CPE Secretariat is available for further information at secretariat@cancerpatientseurope.org.

Choose the type of membership you would like to sign/join*

FULL MEMBERASSOCIATE MEMBER

FULL MEMBER

Please fill in the following details

1) ORGANISATION

Organisation name (in English)*

Organisation name (in the original national language)*

Acronym/abbreviation (e.g., CPE)*

Organisation address*

Postal code*

City*

Country*

General email address*

Phone number with country code*

2) THE LEGAL REPRESENTATIVE OF YOUR ORGANISATION

Name and surname of the legal representative*

Position in your organization*

ChairpersonCEOOther

Please specify:

Email address of the legal representative*

Phone number of the legal representative (with country code)*

3) THE PERSON REPRESENTING YOUR ORGANISATION IN CPE (if different from the legal representative)

Name and surname of the representing person

Position of the representing person in your organization

Email address of the representing person

Phone number of the representing person (with country code)

Aims, activities and geographical basis for your organisation/group

Please provide a short description of your organisation's aims and activities*

The organisation is:*

Umbrella organisationCancer patient organisationOther

Please specify:

The geographical basis for my/our work is:*

Local (my city, my county or province)NationalInternational

Final declarations

NOT-FOR-PROFIT - I declare that the organization I represent is a non-profit organization (as
organization member) / I declare that I have no financial interest in CPE (as individual member)*

I declare

PRIVACY POLICY - The personal information provided on this form will be used by Cancer Patients
Europe ASBL for the sole purpose of registering your membership. No information will be shared without your consent.
You can withdraw your information at any time. Please refer to CPE Privacy Policy:
https://cancerpatientseurope.org/privacy-policy/*

I accept

WEBSITE CONTENT - By completing this form I consent the unremunerated use of the given data by
Cancer Patients Europe, for the purpose of updating the website members' page

I accept

MEMBERS' NEWSLETTER - I accept CPE keeps me informed on its activities via its newsletter*

I accept

ASSOCIATE MEMBER

After selecting the type of entity you are, please fill in the requested details

I am*

An organisation or a groupAn individual

Organisations or Groups

1) ORGANISATION/GROUP

Organisation/Group name (in English)*

Organisation/Group name (in the original national language)*

Acronym/abbreviation (e.g., CPE)*

Address*

Postal code*

City*

Country*

General email address*

Phone number with country code*

2) THE LEGAL REPRESENTATIVE OF YOUR ORGANISATION/GROUP

Name and surname of the legal representative*

Position of this person in your organization/group (if applicable)*

Email address of this person

Phone number with country code*

3) THE PERSON REPRESENTING YOUR ORGANISATION/GROUP IN CPE (if different from the legal
representative)

First and last name

Position of this person in your organization/group

Email address of this person

Phone number with country code (if possible)

Aims, activities and geographical basis for your organisation/group

Please provide a short description of your organisation's aims and activities*

The organisation is:*

Umbrella organisationCancer patient organisationOther

Please specify:

The geographical basis for my/our work is:*

Local (my city, my county or province)NationalInternational

Final declarations

NOT-FOR-PROFIT - I declare that the organization I represent is a non-profit organization (as
organization member) / I declare that I have no financial interest in CPE (as individual member)*

I declare

I accept

WEBSITE CONTENT - By completing this form I consent the unremunerated use of the given data by
Cancer Patients Europe, for the purpose of updating the website members' page

I accept

MEMBERS' NEWSLETTER - I accept CPE keeps me informed on its activities via its newsletter*

I accept

YOUR PERSONAL DATA

Name and Surname*

Date of birth*

Your affiliation (if any)

Address (street, postal code, city)*

Country*

Email*

Phone number with country code*

I am*

medical doctorresearcherpatientpatient advocatecarerhealth care providerOther

Please specify:

Final declarations

NOT-FOR-PROFIT - I declare that the organization I represent is a non-profit organization (as
organization member) / I declare that I have no financial interest in CPE (as individual member)*

I declare

I accept

WEBSITE CONTENT - By completing this form I consent the unremunerated use of the given data by
Cancer Patients Europe, for the purpose of updating the website members' page

I accept

MEMBERS' NEWSLETTER - I accept CPE keeps me informed on its activities via its newsletter*

I accept