If you are a patient support group please complete the form below to become a member.

Organisation details
Organisation name
Name of President/Chief Executive/Chair
When was the organisation established
Organisation acronym
Is your organization:
A foundation
 Yes No
An institute/clinic/hospital/research facility
 Yes No
Registered as non-profit
 Yes No
Date registered
Contact name
Address
Telephone
Email
Fax
Website
Organisation profile
Does your organisation deal with
 Myeloma only General hematology All blood cancers

How many people/members are registered with your organisation in total?

How many myeloma patients are registered with your organisation?

How many care-givers/family members/partners are registered with your organisation?

Organisation activities
Which of the following do you provide:
 Information Helpline Support groups Website Patient/family days Advocacy Research

Any additional details on your organisational aims and activities:

Are you a member of:

The European Cancer Patient Coalition (ECPC)?
 Yes No

EURORDIS (Rare Diseases Europe)?
 Yes No

The Lymphoma Coalition?
 Yes No

Any other umbrella, European or international organisation. If so, please give the details below

Agreement
What type of membership are you applying for?
 Full Associate

I agree with the MPE Constitution
 Yes No

View the Constitution at www.myelomapatientseurope.org