Join us - CLL Advocates Network

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

FULL = non-profit patient organisations with a sole or significant focus (demonstrated by clear evidence of existing activities) on the needs of CLL patients. // ASSOCIATE = non-profit patient organisations with a partial focus on the needs of CLL patients but do not have a dedicated CLL patient program. // SUPPORTER = individuals with an interest in CLL patient support and advocacy OR individuals strongly motivated to start CLL patient groups in their own countries.

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:

Facebook:

Twitter:

LinkedIn:

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address:*

Subscribe to CLLAN´s Newsletter "CLL Matters"*

Yes
No

Do you consent to be added to the CLLAN’s distribution list and contacted via email?*

Yes
No

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:*

13. Logo of your organisation (jpg, png, gif):

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

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.

Membership Form

1. Please provide the following personal information:

7. Organisation's contact information:

8. Key contact person at your organisation: