Membership Form_copy

Please fill in electronically all grey areas of this form, print out and send this form together with the required documents and a cover letter signed by your chairperson indicating that you want to join EFA and accept the EFA Statutes and Internal rules to EFA Office, 35 Rue du Congrès, 1000 Brussels, Belgium. Please see page 4 for the membership criteria.

Organisation details

Coalition Membership

Are you joining as a coalition with other organisations in your country?	[select menu-775 "YES" "NO"]
If ‘Yes’ is it a registered coalition?	[select menu-776 "YES" "NO"]
If ‘No’ please make sure that each of the ad hoc coalition partners fills in one application form, attach the documents required and nominate the same contact person and delegate to general meeting.	[file file-631 12/]
Which coalition member pays the membership fee to EFA?	[text text-613 12/]

Contact Details

Name of the organisation or the coalition	[text text-614 12/]
Names of the ad hoc coalition partners involved with EFA	[text text-615 12/]
Name of EFA contact person	[text text-616 12/]
Full Address	[text text-617 12/]
Telephone	[text text-618 12/]
Fax	[text text-621 12/]
E-mail	[text text-619 12/]
Website (if applicable)	[text text-620 12/]

Delegate to the EFA General Meeting of Members

Name	[text text-622 12/]
Telephone(if different from above)	[text text-623 12/]
Fax (if different from above)	[text text-624 12/]
E-mail (if different from above)	[text text-625 12/]

PRINCIPLES FOR EFA MEMBERSHIP

Represented Diseases

[text text-626 12/]

Accountability and Democracy

Membership:

Do you have members?	[select menu-777 "YES" "NO"]
If ‘Yes’ who are they?
% patients/carers	[text text-628 12/]
% health care professionals	[text text-629 12/]
% others	[text text-630 12/]
if you have others please specify	[text text-631 12/]
If ‘No’ what type of organisation are you?	[text text-632 12/]

Governance:

The highest governing body of your organisation is:

[text text-633 12/]

Who elects your governing body?

[text text-634 12/]

If not elected by patients/carers or their elected representatives, how is patient perspective incorporated in the policy making of your organisation?

[text text-635 12/]

Legitimacy

Registration number:	[text text-636 12/]
Year and country of registration:	[text text-637 12/]
Is your organisation’s status non-profit/charity?	[select menu-778 "YES" "NO"]
Please attach a copy of your Statutes/Constitution or indicate here the website address where it is available:	[file file-632 12/]

Indepedence and transparency

Are you a non-governmental organisation?	[select menu-779 "YES" "NO"]
Are you affiliated with any political group or similar?	[select menu-780 "YES" "NO"]
Source of income: Please answer in % Amount
Membership fees	[text text-638 12/]
Government	[text text-639 12/]
Fundraising	[text text-640 12/]
Sponsors	[text text-641 12/]
Name of Current Sponsors	[text text-642 12/]
Or other (Please specify)	[text text-643 12/]
Please attach your last approved financial accounts or indicate here the website address where they are available:	[file file-633]

Aims and Objectives

What are your organisations aim/mission and main objectives?

[textarea textarea-214 ]

Are you willing to actively take part within the EFA network?

[select menu-781 "YES" "NO"]

Do you have Specific expectations for the EFA network

[textarea textarea-215 ]

Statistical Questions

Population of Country

[text text-644 12/]

Representation

How many members do you have?	[text text-645 12/]
How many local member organisations/branches?	[text text-646 12/]
How many FTE’s (full time equivalents)?	[text text-647 12/]
How many volunteers?	[text text-648 12/]
Prevelance(Answer in % of Population)
Asthma	[text text-649 12/]
COPD	[text text-650 12/]
Allergy	[text text-651 12/]
Allergic Rhinitis	[text text-652 12/]
Atopic Eczema	[text text-653 12/]
Urticaria	[text text-654 12/]
Food Allergy	[text text-655 12/]

[captchac captcha-612]
[captchar captcha-612]

[submit "Send"]

[your-subject] [your-name] <[your-email]> From: [your-name] <[your-email]> Subject: [your-subject]

MEMBERSHIP APPLICATION FORM Please fill in electronically all grey areas of this form, print out and send this form together with the required documents and a cover letter signed by your chairperson indicating that you want to join EFA and accept the EFA Statutes and Internal rules to EFA Office, 35 Rue du Congrès, 1000 Brussels, Belgium. Please see page 4 for the membership criteria. Organisation details

Coalition Membership

Are you joining as a coalition with other organisations in your country?
[select menu-775]

If ‘Yes’ is it a registered coalition?
[select menu-776]

If ‘No’ please make sure that each of the ad hoc coalition partners fills in one application form, attach the documents required and nominate the same contact person and delegate to general meeting.
[file-631]

Which coalition member pays the membership fee to EFA?
[text-613]

Contact Details

Name of the organisation or the coalition
[text-614]

Names of the ad hoc coalition partners involved with EFA
[text-615]

Name of EFA contact person
[text-616]

Full Address
[text-617]

Telephone
[text-618]

Fax
[text-621]

E-mail
[text-619]

Website (if applicable)
[text-620]

DELEGATE TO THE EFA GENERAL MEETING OF MEMBERS

Name
[text-622]

Telephone
[text-623] (if different from above)

Fax
[text-624] (if different from above)

E-mail
[text-625] (if different from above)

PRINCIPLES FOR EFA MEMBERSHIP

Represented Diseases
[text-626]

Accountability and Democracy

Membership:

Do you have members?
[select menu-777]

If ‘Yes’ who are they?

% patients/carers
[text-628]

% health care professionals
[text-629]

% others
[text-630]

if you have others please specify
[text-631]

If ‘No’ what type of organisation are you?
[text-632]

Governance:

The highest governing body of your organisation is:
[text-633]

Who elects your governing body?
[text-634]

If not elected by patients/carers or their elected representatives, how is patient perspective incorporated in the policy making of your organisation?
[text-635]

LEGITIMACY

Registration number:
[text-636]

Year and country of registration:
[text-637]

Is your organisation’s status non-profit/charity?
[select menu-778]

Please attach a copy of your Statutes/Constitution or indicate here the website address where it is available:
[file-632]

Indepedence and transparency

Are you a non-governmental organisation?
[select menu-779]

Are you affiliated with any political group or similar?
[select menu-780]

Source of income:
Please answer in % Amount

Membership fees
[text-638]

Government
[text-639]

Fundraising
[text-640]

Sponsors
[text-641]

Name of Current Sponsors
[text-642]

Or other (Please specify)
[text-643]

Please attach your last approved financial accounts or indicate here the website address where they are available:
[file-633]

Aims and Objectives

What are your organisations aim/mission and main objectives?
[textarea-214]

Are you willing to actively take part within the EFA network?
[select menu-781]

Do you have Specific expectations for the EFA network
[textarea-215]

Statistical Questions

Population of Country
[text-644]

Representation

How many members do you have?
[text-645]

How many local member organisations/branches?
[text-646]

How many FTE’s (full time equivalents)?
[text-647]

How many volunteers?
[text-648]

Prevelance(Answer in % of Population)

Asthma
[text-649]

COPD
[text-650]

Allergy
[text-651]

Allergic Rhinitis
[text-652]

Atopic Eczema
[text-653]

Urticaria
[text-654]

Food Allergy
[text-655]

[submit "Send"]

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