Membership Application Form

Name of Organization: (in English) *

Name of Organization: (in your national language) *

Disease Area: *

Geographic Focus : *

Local

National

Website: *

E-Mail Address (executive / office address) *

Telephone Number (incl. country code): *

Fax Number: (incl. country code): *

Organization Chair/President *

E-mail Address Chair / President *

2. Principal Contact Person

Name: *

Position: *

Direct E-mail Address: *

Direct Telephone: *

Direct Fax: *

How many MDS Patients, families and caregivers does your organization approximately represent? *

3. English Language Summary of Your Organization’s Goals and Activities

Activities: *

Other Activities

4. Please make sure you meet the MDS Alliance membership criteria (https://www.mds-alliance.org/become-a-member/)

If you don't meet the criteria please contact us so that we can discuss how to help you.

5. Existing Memberships

Is your organization already a member of other alliances or coalitions?

Already a member of other alliances or coalitions? *

No

Yes -If yes: Please provide a list of organizations of which your organization is a member.

We belong to these organizations:

Does Your Organization Focus on Diseases in Addition to MDS? *

No

Yes - If yes: Please list

What diseases does your organization focus on?

Does Your Organization have a medical advisor who reviews the contents of your website for medical correctness? *

No

Yes - If yes: Please list his/her name, contact details and email:

Contact information for medical advisor:

6. Confirmation and Signature

I hereby confirm that the information given above is accurate, and that my organization is eligible to be a Member of the MDS Alliance as defined above.

Signed: *

Position: *

Date: *