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Centre Membership Application Form

Please complete all the relevant fields below. Required fields are marked with an asterisk.

Sponsorship by two Full or Associate EBMT Members is required. If you are applying as an LMIC member and are unable to provide sponsorship details, please contact the membership department at and we will assist you with this.

You will receive an invoice from the Financial Department following acceptance of your application.

Institution

Are you appliying for LMIC Membership?
If you checked "Yes" above, you must submit proof of employment in an LMIC country. This is any document that proves you are living/working in that country and includes your photo, name, and home or work address (a residency card, work ID, etc.).
The list of LMIC countries can be consulted here
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64 MB limit.
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Sponsorship

Sponsor 1
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Sponsor 2
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Principal activity

Tick one box that best describes the nature of the applicant institution
If the applicant institution is a clinical unit, tick the relevant boxes to indicate whether the team performs harvest and/or auto and/or allo and whether it is adult or paediatric:
Commitment
By signing below, I certify that I and the members who form part of our application are actively involved in the scientific and/or clinical area of blood or marrow transplantation (or transplantation of other haematopoietic tissue). Where the institution is a clinical transplant centre there is a duty on Full Members to report all consecutive haematopoietic stem cell transplants and follow-up data.

I certify that I am willing to report the results of transplants performed at my centre to the EBMT and will submit a minimum of MED A data on all patients on an annual basis.

I confirm that I will comply with the EU General Data Protection Regulation (GDPR 2016/679) in all aspects relating to the transfer of data to the EBMT. In particular, I confirm that all patients whose registrations are being forwarded to the EBMT have given consent for the data to be sent to the EBMT by signing a Patient Consent Form for Data Registration.
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64 MB limit.
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The personal data provided will be processed according to the General Data Protection Regulation (GDPR 2016/679) and incorporated to a file property of EBMT which will be allocated in the EEA (European Economic Area) or in countries that are provided with the same level of protection for privacy such as countries that adhere to EU-US and Swiss-US Privacy Shield Frameworks .

Data Subjects have the right of access to his or her data and the right to rectification of any inaccurate or incomplete personal data. The Data Subject also has the right to withdraw consent, this wish will be respected, and the personal will no longer be made available. If the processing operation is unlawful the Data Subject has the right to request deletion of that data. Please write to data.protection@ebmt.org

For further information please go to the Privacy Policy.

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The personal data provided will be processed according to the General Data Protection Regulation (GDPR 2016/679 ) and incorporated to a file property of EBMT which will be allocated in the EEA (European Economic Area) or in countries that are provided with the same level of protection for privacy such as countries that adhere to EU-US and Swiss-US Privacy Shield Frameworks.
Data Subjects have the right of access to his or her data and the right to rectification of any inaccurate or incomplete personal data. The Data Subject also has the right to withdraw consent, this wish will be respected, and the personal will no longer be made available. If the processing operation is unlawful the Data Subject has the right to request deletion of that data. Please write to data.protection@ebmt.org