Application for Healthcare Professional or Scientific Research Organisations

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Address including region or state (of head office Association)
Does your organisation comply with all the relevant regulations (as defined locally for your type of organisation) AND do you remain in good standing with your local regulatory authorities (in all regulatory areas, financial, governance, democratic and any others applicable to your organisation).
Is your organisation primarily secular rather than religious, not aligned to a political group and open to all technically qualified persons regardless of social class or economic background (other than criterion such as residence in your area of operation)
Do you have any actual or potential conflicts of interest (whether commercial or ideological) relevant to LWA membership or activities?
Do you understand that you must proactively report any changes to your conflicts and potential conflicts of interest as they occur, and failure to do so may result in your membership being terminated?
Click or drag files to this area to upload. You can upload up to 3 files.
Only the following file formats are permitted: doc (docx), ppt (pptx, pps, ppsx), odt, pdf, xls (xlsx). Maximum file size 15 MB
Click or drag files to this area to upload. You can upload up to 3 files.
Only the following file formats are permitted: doc (docx), ppt (pptx, pps, ppsx), odt, pdf, xls (xlsx). Maximum file size 15 MB

Contact Person Name/Appointed Representative for LWA

Name
Street Address including region or state
Click or drag files to this area to upload. You can upload up to 3 files.
Only the following file formats are permitted: doc (docx), ppt (pptx, pps, ppsx), odt, pdf, xls (xlsx). Maximum file size 15 MB

Consent request to the Applicant/Contact Person/Appointed Representative

Do you agree that LWA may publish on its web and other media (e.g. social networks linked to LWA) the following data: full name, address, landline, mobile phone, fax, e-mail, membership position (e.g. founder, member, etc.), professional activity, in order to achieve the association's aims as set out in the Statute?
PRIVACY POLICY