HCC Form

I. General information

Institution name

Institution mailing address

City

State

Pincode

II. Information institutional head (Director/Dean)

Prefix

First name

Last name

Title

Professional designation/credential (s)

Email

Work phone

Name of assistant/secretary

Email id

III. Head of department

Prefix

First name

Last name

Title

Professional designation/credential (s)

Email

Work phone

Name of assistant/secretary

Email id

IV. Representive/Contact person information

Prefix

First name

Last name

Middle initial

Title

Professional designation/credential (s)

Email

Work phone

Name of assistant/secretary

Email

Review preferences carefully: Select all coalitions that you would like to be actively involved in

Collaboration for multi-centre research
Collaboration for data sharing for patterns of care
Participation in educational activities only

Collaboration for multi-centre research and collaboration for data sharing for patterns of care ethics committee approval

Ethics committee approval

Yes

No

Upload ethics committee approval letter

Is your institution a member of any similar network/organisation/consortium?

Yes

No

Consent for being listed on our website:

Yes

No

Upload logo

Signature (Head of the institute)

Enter your full name

HEMATOLOGY CANCER CONSORTIUM

Institutional Membership Application For New Members

I. General information

II. Information institutional head (Director/Dean)

III. Head of department

IV. Representive/Contact person information

Review preferences carefully: Select all coalitions that you would like to be actively involved in