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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Name organization *
City *
Country *
Link to website of your Ataxia PAO
*
First name contact person *
Last name contact person *
Title contact person *
Gender contact person *
Email address contact person *
Phone number contact person ([+][country code]-[area code]-[local phone number]) *
Sector *
Role contact person *
We would like to list all AGI partners on the website with the names of the organizations, unless you strongly object to this.
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Would you like to subscribe to our newsletter? *
By submitting your partnership application to the AGI, you agree that we manage your personal data according to GDPR standards. *
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. *
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