Name of organisation If you are a registered organisation please provide your registration number and regulator details Registered office address or main operating address including postal/zip code and country Please state the Condition/illness/diseases that you support Email Address Telephone Number Main contact person (full name) Name of Treasurer or accountant Year Founded Name of Founder Name of Trustees or governing Committee members Are you a member of any other organisations, alliances or professional bodies (please list all) Do you currently collaborate with any hospitals, medical centres, charities, non profit organisations or similar (please list all) Has the organisation or any of it’s staff or volunteers been the subject of any complaints, investigations or similar? (please give details including dates) What are the aims and objectives of your organisation? What is your annual voluntary income? (please provide your last financial year figure) What is your first language? What other languages do you speak? Please declare any conflicts of interest Please state how being a member of IDEA Alliance will benefit your organisation, the alliance and most importantly patients? Declaration: I declare that I am authorised to apply for membership on behalf of the organisation stated on this application form and that the information provided is true to the best of my knowledge and I understand that any false or incorrect information could lead to the termination of membership of the alliance. I also agree to put the interest and reputation of the alliance at the forefront of all activities and ventures and agree to abide by the terms & Conditions as set out in the membership handbook. By checking this box you accept the declaration Calling us or entering your information onto our webform will require us to process your personal data. Please refer to our Privacy Policy for further details. Δ
