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Membership Form
1. Please provide the following personal information:
First Name
Last Name
Email Address:
Phone Number:
2. Type of membership you are applying for:
Full
Associate
Supporter
3. You/your organisation:
Is willing to abide by the CLLAN Code of Conduct.
Is willing to share and work with other members to build a strong CLL global community.
Is interested in furthering the objectives of CLLAN.
The following questions pertain to organisations. If you are applying to become a Supporter, please go to question 11.
4. Organisation's name. Please provide in your native language, as well as an English translation (if necessary). If you use an abbreviation (i.e. CLLAN) please list that as well.
5. Your organisation: (Please check all that apply)
Has an exclusive focus on providing services to and/or supporting patients with CLL.
Has a partial focus on providing services to and/or supporting patients with CLL.
Is recognized and/or registered as a non-profit organisation in good standing in our country.
6. Number of members or patients with CLL your organisation represents today:
7. Organisation's contact information:
Website:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email Address:
8. Key contact person at your organisation:
Name:
Title:
Email Address:
Phone Number:
9. Please provide a brief description of your organisation, including the programs, activities or services that support patients with CLL:
10. Please list topics your organisation has experience in that could contribute to CLLAN:
The following questions pertain to individuals. If you are applying as an organisation, please go to the end of the form.
11. Please provide a brief description of yourself, including your experience with CLL and any activities you personally undertake to support patients with CLL:
12. Please list topics you have experience in that could contribute to CLLAN:
Thank you for your application. It will be reviewed by the CLLAN Steering Committee at the next scheduled meeting. You will be contacted if there are questions about your application and informed of the decision on your membership once it has been made. If you have any questions, comments or concerns, please list them here or email us at info@CLLAdvocates.net.
CLL Information
Membership
Initiatives
Resource Hub
COVID-19 resources
Statement
Upcoming COVID-19 Online Events
Recent Events
Advocacy activities
Scientific studies & literature
Patient-Lead Studies
News & Events
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