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Membership form

Please complete this form to select Membership type, thank you

Organisation name *

Select a membership type *

Title

Other title *

First name *

Preferred first name

Middle name

Last name *

Previous last name

Suffix 1

Suffix 2

Pronouns

Custom Pronouns

Address type

Address line 1 *

Address line 2

Address line 3

County/ state

City *

Country *

Post code *

Email type 1

Email 1 *

Email type 2

Email 2

Email type 3

Email 3

Phone type

Phone country code *

Phone area code

Phone number *

Fax

Web site

Board Chairman

President's name

Head of Staff

E-mail address

Mission Statement

Describe the region served by your organization:

Number of Members

Year organization was founded

Describe your significant national activities in the last past year

Please list the names of the board members and if they are patients or medical professionals

Additional names and e-mail addresses for IFPA information and newsletters

Signed Declaration, with date and location:

Address

Slottsbacken 8, Stockholm, Sweden

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Membership form

Please complete this form to select Membership type, thank you

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