MPN AN Membership Registration Form

Thank you for your interest in joining the MPN Advocates Network.

Patient organizations are eligible to apply for membership of MPNAN, as long as they meet the following criteria:

Have a sole or partial focus on providing services to and/or supporting patients with MPN.
Are recognised as a non-profit organisation in good standing in their country.
Willing to work with and cooperate with other member organisations with the same objectives.

If you do not currently meet the criteria for membership but are interested in starting a MPN group in your own country, please email info@mpn-advocates.net

Please provide the following personal information:

Name of Organization
Registrations Number
Contact Name
Address
City
Country
Telephone #
Email

	Social Media Platform (Facebook, Twitter, etc.)	Updated Regularly? Yes or No	Private or Open Portal
Social Media #1
Social Media #2
Social Media #3
Social Media #4
Other
Website

Please provide a brief description of your organization, including the programs, activities or services that support patients with MPN:

Your organization has experience in the following topics that could contribute to MPNAN:

Number of members or patients your organization represents today:

If you have any questions, comments or concerns, please list them here or email us at info@mpn-advocates.net