Are you joining as a coalition with other organisations in your country?

If ‘Yes’ is it a registered coalition?

If ‘No’ please make sure that each of the ad hoc coalition partners fills in one application form, attach the documents required and nominate the same contact person and delegate to general meeting.

Which coalition member pays the membership fee to EFA?

Name of the organisation or the coalition

Names of the ad hoc coalition partners involved with EFA

Name of EFA contact person

Full Address

Telephone

Fax

E-mail

Website (if applicable)

Name

Telephone(if different from above)

Fax (if different from above)

E-mail
(if different from above)

Represented Diseases

Do you have members?

If ‘Yes’ who are they?

% patients/carers

% health care professionals

if you have others please specify

If ‘No’ what type of organisation are you?

The highest governing body of your organisation is:

Who elects your governing body?

If not elected by patients/carers or their elected representatives, how is patient perspective incorporated in the policy making of your organisation?

Registration number:

Year and country of registration:

Is your organisation’s status non-profit/charity?

Please attach a copy of your Statutes/Constitution or indicate here the website address where it is available:

Are you a non-governmental organisation?

Are you affiliated with any political group or similar?

Membership fees

Government

Fundraising

Sponsors

Name of Current Sponsors

Or other (Please specify)

Please attach your last approved financial accounts or indicate here the website address where they are available:

What are your organisations aim/mission and main objectives?

Are you willing to actively take part within the EFA network?

Do you have Specific expectations for the EFA network

Population of Country

How many members do you have?

How many local member organisations/branches?

How many FTE’s (full time equivalents)?

How many volunteers?

Prevelance(Answer in % of Population)

Asthma

COPD

Allergy

Allergic Rhinitis

Atopic Eczema

Urticaria

Food Allergy