Patient Advocacy Group (PAG) Affiliate Membership Application

Please complete all required sections below to enable us to process your application

PAG details

Organisation Name *

Street Address

City *

Postal Code *

Country *

State/Province

Email *

Website

Instagram

Facebook

X (Twitter)

Primary contact

First Name *

Last Name *

Job Title

Phone Number

Phone Type

Email *

Patient Advocacy Group details

Country of PAG registration *

Date of PAG registration

Day

Month

Year

PAG registration number

Status of the organisation as defined by the country of registration *

Status of the organisation as defined by the country of registration - Other

Description of PAG aims *

Geographical area of PAG’s activity (e.g. country, region) *

Description of support and information activities offered by PAG to patients *

Please demonstrate their accessibility to patients in Europe

PAG board members: names and status of each person *

PAG clinical/medical advisory board/consultant (names and affiliations, including ESE membership) *

Please note at least one Medical Advisor / Consultant needs to be (or agree to become) a member of ESE

Description of PAG membership *

(Number of members, disease groups, membership fee if any)

Logo of PAG *

More information

Files must be less than 2 MB.
Allowed file types: gif jpg png.

Industry engagement

I confirm that my organisation is transparent about the support being received from industry sources and the purpose of such support. *

Yes

Data privacy

The data that you submit via this form will be used and stored securely in accordance with ESE’s Privacy Policy.

Please confirm you have read and agree to the above Privacy Policy *

I have read, understand and agree to ESE’s privacy policy

Leave this field blank