Name of Organisation
clinical or research group

Please see notes

Organisation Type

Address

Please see notes

Town

County/State/Province

Postcode

Country

Telephone Number

Fax

Title of Contact person

First Name of Contact person

Surname of Contact person

Direct dial for Contact person

Organisation Email

Organisation Website

What is the purpose of the organisation, clinical or research group? Please see notes

What is the main focus of activity of the organisation, clinical or research group?

If your organisation is a registered charity, please give the charity number and country of registration Please see notes

Is your organisation, clinical or research group part of an umbrella group?

If you are a clinical or research group, are other groups in your institution seeking membership?

In which country is your organisations main area of activity?

Andorra Antigua and Barbuda Argentina Australia Austria Bahamas Bangladesh Barbados Belgium Belize Bolivia Borneo Botswana Brazil Brunei Bulgaria Burkina Faso Cambodia Canada Cape Verde Chile China Colombia Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dominica Dominican Republic Ecuador Egypt El Salvador Estonia Ethiopia Falklands Islands Fiji Finland France French Polynesia Gambia Germany Ghana Greece Greenland Grenada Guadeloupe Guatemala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kenya Laos Luxembourg Madagascar Malawi Malaysia Malta Mauritius Mexico Mongolia Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Norway Panama Papua New Guinea Paraguay Peru Peurto Rico Philippines Poland Portugal Romania Russian Federation Saint Lucia Samoa Senegal Seychelles Singapore Slovakia Slovenia South Africa South Korea Spain Sri Lanka Swaziland Sweden Switzerland Taiwan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Uganda Ukraine United Kingdom United States of America Uruguay Vanutu Venezuela Vietnam Yugoslavia Zambia Zimbabwe

To what degree are patients involved in your organisations activities (e.g. Member of the governing board, committee membership etc.)

Is your organisation independent of government, political parties and commercial organisations?

If Applicant Is a Patient Organisation:

In not more than 75 words (English) please state the aims of the organisation and the work it undertakes (NB This will be the description of the objectives of your organisation and the activities that you offer, which GOLD will provide on its website, along with the link to your site) ?

Please give details of current research projects being undertaken and/or funded by your organisation.

Do you have a medical or scientific advisory committee?

Do you peer review all grant applications?

If you fund research, how much (in monetary value) was funded in each of the following years

Please give details of publications including language available and price.

Please give details of all meetings and conferences planned for 2005 onwards with dates and venues. Please indicate if these are open meetings or by invitation only, and if local, regional or international.

If Applicant Is a Clinical Group Or Treatment Centre please detail below the Research interests of laboratory/clinic