APPLICATION FOR FULL MEMBERSHIP OF ASKLEPIOS

The form comprises of 4 sections requesting information in order to assist in your application for membership of ASKLEPIOS

Section 1: Organisational status/profile
 
Please tick to confirm that you are:
Governmental
Non-governmental
Non-profit distributing
Non-political
EU Country

Contact details:

Organisation details
Full legal name of organisation
Usual name/acronym
Address
Telephone number
Fax number
Organisation Email
Website


Section 2: Description of your organisation
 
Please describe your organisation in around 200 words, covering topics such as objectives, sectoral areas of interest, age, main sources of funding, number of staff etc.




Section 3: Giving and Gaining
 
This question is for our information purposes only.
What does your organisation hope to gain from membership of ASKLEPIOS?


What can your organisation offer ASKLEPIOS?




Section 4: Declaration
 
We hereby apply for membership of ASKLEPIOS. We agree to be bound by the constitution of ASKLEPIOS, and we undertake to aspire to ASKLEPIOSís Statement of Principles.

Name:   Date:  

Referee:

Please provide contact details for a referee whom the committee can contact for further information if necessary. The referee should be someone with knowledge of your organisation, for example as a funder, partner organisation or beneficiary.

Name
How does this referee know your organisation?
Would you like ASKLEPIOS to inform you before contacting your referee?:
Yes
No, not necessary