ANACARE Apply Now - Global Allergy and Asthma Excellence Network

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

ANACARE Department Head Name

ANACARE Department Head Email

Department Deputy

ANACARE Department Deputy Name

ANACARE Department Deputy Email

Application

Dear Professor Antonella Muraro,

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

Explaination*

I have read the 32 requirements and confirm that our center fulfills the requirements and deliverables. Thank you very much in advance for your answer.

Please fill in the Power Point document “Center Presentation for Audit_PP template“, save it as a pdf file and upload it here. This presentation is mandatory for the application process and basis for the audit.

Download the presentation template here

Upload Center Presentation document*:

* Please attach your file as a PDF (max. 25 MB).

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 website of Global Allergy And Asthma Excellence Network.

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:

Department Data:

Application

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

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

Signature

Applicant Name *

Applicant Email *

Application Date *

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