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

Department Head Name

Department Head Email

Department Deputy

Department Deputy Name

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 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 website on the website of Global Allergy And Asthma Excellence Network. You can find examples of our centers' profiles on ADCARE page: https://global-allergy.network/anacare/#find-adcare or on https://global-allergy.network/cores/#aa29203c

My center is already a member of the following Global Allergy and Asthma Excellence networks (required):

ACAREADCAREARIACAREUCARENone of the above

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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