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AGI partnership application
By filling out this form, you apply for partnership of the Ataxia Global Initiative (
http://ataxia-global-initiative.net/
), according to the rights and guidelines set out in its charter:
http://ataxia-global-initiative.net/governance/charter/
.
Upon receiving this form, the Steering Committee will consider your application. Once approved, you will receive a membership certificate, which is valid for 3 years.
If you have any questions, please contact
ataxiaglobaloffice@med.uni-tuebingen.de
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* Indicates required question
Name organization
*
Your answer
City
*
Your answer
Country
*
Your answer
Link to website of your Ataxia PAO
*
Your answer
First name contact person
*
Your answer
Last name contact person
*
Your answer
Title contact person
*
Your answer
Gender contact person
*
Female
Male
Prefer not to say
Other:
Email address contact person
*
Your answer
Phone number contact person ([+][country code]-[area code]-[local phone number])
*
Your answer
Sector
*
Academia
Industry
Patient organization
Governmental organization
Other:
Role contact person
*
Clinician
(Laboratory) Scientist
Patient representative
Management
Other:
We would like to list all AGI partners on the website with the names of the organizations, unless you strongly object to this.
I object to including my organization's name on the AGI website
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Would you like to subscribe to our newsletter?
*
Yes
No
By submitting your partnership application to the AGI, you agree that we manage your personal data according to GDPR standards.
*
I agree
By submitting your partnership application to the AGI, you confirm that you have read the charter and agree with the rights and guidelines for partners listed there.
*
I agree
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