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All.Can Membership Application Form
Please fill out this form and submit it here. We ask you to check All.Can's membership criteria before completing: https://www.all-can.org/get-involved/membership/
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1
In which capacity are you applying for All.Can membership?
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Organisation member
Individual member
Organisation member
Individual member
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2
Personal Details
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First Name
Last Name
Organisation
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3
Your Work in relation to All.Can
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Please give a short description of your work and how it is related to All.Can. Please describe your interest in All.Can, and how the goals and objectives of All.Can fit with your organisation’s goals.
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4
Contribution to All.Can as Individual Member
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Please explain what added value you can bring to All.Can. Finally, please mention any contributions you are interested in (e.g. research projects to which you wish to contribute, events to co-host etc.)
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5
About Your Organisation
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Name of Organisation
Country Registered
Website URL
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6
Type of Organisation
*
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Patient advocacy organisation
Professional or scientific society
Cancer leagues
Academic institution
Private company
Healthcare payer and provider group
Other
Patient advocacy organisation
Professional or scientific society
Cancer leagues
Academic institution
Private company
Healthcare payer and provider group
Other
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7
Type of Organisation - Please Specify
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8
Organisation Mission
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9
Organisation Leadership
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Please add list of or link to overview of Board / Executive Committee Members (names, country, profession and/or affiliation - as applicable)
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10
Statutes
*
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Please upload or provide link to your organisation's statutes / articles
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11
Your Organisation's Work
*
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Please give a short description of your organisation's work and how it is related to All.Can. Please describe your interest in All.Can, and how the goals and objectives of All.Can fit with your organisation’s goals.
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12
Contribution to All.Can as Organisation Member
*
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Please explain what added value your organisation can bring to All.Can. Finally, please mention any contributions you are interested in (e.g. research projects to which you wish to contribute, events to co-host etc.)
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13
Type of Membership
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General member (not-for-profits)
Funding member (private sector)
General member (not-for-profits)
Funding member (private sector)
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14
Please tick All.Can Working Group(s) of interest to you
*
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Research and Evidence
Public Affairs
National Initiatives
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15
Conflicts of Interest
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Please state any potential conflicts of interest which we should be made aware of
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16
Contact Details: Primary Contact
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We ask that one person is nominated per organisation as primary contact for All.Can membership, and that a secondary contact is established who can attend meetings in your absence.
First Name
Last Name
Title and position in organisation
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17
Contact Details: Secondary Contact
First Name
Last Name
Title and position in organisation
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18
Contact Details: Submitter
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First Name
Last Name
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19
Do you have any other Comments or Questions?
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20
I DECLARE THE INFORMATION SUBMITTED ABOVE TO BE CORRECT AND ACCURATE
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