Patient Advocacy Group Affiliated Membership Application Form

To apply please complete the form below

For questions or to discuss your application please contact ESE at info@ese-hormones.org

Patient Advocacy Group (PAG) Affiliate Membership Application Form

PAG Name *

Address *

Main email address *

Main contact person * Please provide name, function, email address, telephone number

Country of PAG registration *

Date of PAG registration and registration number (if applicable) *

Status of the organisation as defined by the country of registration * Non-profit, charity or other applicable

Description of PAG aims * Please demonstrate the focus on endocrine disease

Geographical area of PAG’s activity (e.g., country, region) * Please demonstrate the focus on Europe

Description of support and information activities offered by PAG to patients * Please demonstrate their accessibility to patients in Europe

PAG Board members: names and status of each person * State whether patient, relative, professional, medical/clinically qualified

PAG Clinical/Medical advisory board/consultant (names and affiliations, including ESE membership) * Please note at least one Medical Advisor / Consultant needs to be (or agree to become) a member of ESE

Description of PAG membership * Number of members, disease groups, membership fee if any

Website URL *

Social media contact details * Facebook, LinkedIn, Twitter, other

Logo of PAG * To be included as a .png or .jpeg file, 300 dpi minimum - high resolution

Industry engagement

I confirm that my organisation is transparent about the support being received from industry sources and the purpose of such support. *

I accept ESE‘s Privacy Policy (https://www.ese-hormones.org/privacy-policy/)

I confirm that I give permission to have my organisation’s details added to the ESE website and that the details provided in this form are correct.

Form completed by * Please provide full name, function and email address

Patient Advocacy Group Affiliated Membership Application Form

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