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GDLN Affiliation: Expression of Interest(EI) Form
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* Indicates required question
1.0 Organization information
1.1 Organization Name
*
Your answer
Country
*
Your answer
Organization address
*
Your answer
Postal code
*
Your answer
Direct telephone
*
Your answer
Direct fax
Your answer
Organization website
Please provide your URL
Your answer
Social Media Page
Please provide your URL
Your answer
1.2 Head of the Organization
Name
*
Dr
Mr
Mrs
Ms
Required
Name
*
FIRST NAME / MIDDLE NAME / LAST NAME
Your answer
Job title
*
Your answer
Direct telephone
*
Your answer
Mobile telephone
*
Your answer
E-mail
*
Your answer
1.3 Authorised Contact Person (Nominee from your organization for GDLN contact)
Name
*
Dr
Mr
Mrs
Ms
Required
Name
*
FIRST NAME / MIDDLE NAME / LAST NAME
Your answer
Job title
*
Your answer
Direct telephone
*
Your answer
Mobile telephone
*
Your answer
Email
*
Your answer
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