ANACARE Apply Now - GA²LEN Global Network of Excellence

ANACARE Application form

Center Information

Department Information

Application

Verify Information

Center Information

Clinic Name

Center Name *

Center Address

Street Address*

Address Line 2

City*

State / Provice / Region

ZIP / Postal Code*

Country*

Center Contact Data

Center Email *

Center phone

Center Website

Department Information

Department Email

Department Phone

Department mail address

Department Head

Department Head Name

Department Head Email

Department Deputy

Department Deputy Name

Department Deputy Email

Application

Dear Professor Muraro,

I wish to join the GA²LEN ANACARE Centers of Reference and Excellence and hereby apply for our center to become a ANACARE.

Explaination*

I have read the "32 GA²LEN ANACARE requirements and deliverables" and confirm that our center fulfils the requirements and deliverables.

Please note: Some of the information listed above (including the center’s name and address, contact information for patients, website and logo) may be published on the ANACARE website. You can find examples of our centers' profiles on the "Find an ANCARE" tab of the ANACARE website: HERE

Verify Information

Please review and verify your information before submitting your application. If you need to change your submitted information, click "Previous" at the bottom of this page to go back.

Center Information

Center Name:

Center Address:

Center Contact Data:

Application

Please explain why you want to become an Anaphylaxis Center of Reference and Excellence:

Consent: I have read the "32 GA²LEN ANACARE requirements and deliverables" and confirm that our center fulfils the requirements and deliverables.

Applicant Name *

Applicant Email *

Application Date *

Signature

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Signature *