AffiliateOrgDataSheet040219

WHF Organization Data Sheet

*Affiliate Organization Name: ____________________ (*Underline=required) Rev 2/19/04

*Affiliate Data Manager: _______________________ Title: ____________________

*Phone: _____________________ *Fax: __ -________________________________

*E-mail: _____________________ *City, State / Prov: _________ *Country: ____

Affiliate Contact Person 1: _____________________ Title: _____________________

Phone: ___________________________ Fax: ______________________________

E-mail: ______________________________________

Affiliate Contact Person 2: _______________________ Title: ___________________

Phone: __________________________ Fax: _______________________________

E-mail: ______________________________________

Organization mission statement on back/separate sheet (< 360 characters and spaces, Org Name at top):

Organization focus (Mark your six most important areas of focus and most important regions):

__Pediatric cardiac surgery	__Provides equipment
__Adult cardiac valvular surgery	__Provides disposables / supplies
__Adult ischemic cardiac surgery	__Provides MD professional support
__Pediatric noncardiac thoracic surgery	__Provides nonMD professional support
__Adult noncardiac thoracic surgery	__Needs equipment
__Diagnosis of cardiac disease	__Needs disposables / supplies
__Treatment of cardiac disease (Non surgical)	__Needs MD professional support
__Prevention of cardiac disease	__Needs nonMD professional support

__Organizes projects	Mark your most important regions
__Organizes individual patient treatments	__North America
__Distributes medical equipment	__Mexico or Central America
__Provides project financial support	__South America
__Provides project non-financial support	__Western Europe
__Provides individual patient treatment financial support	__Eastern Europe or Russia
__Provides individual patient treatment non-financial support	__North Africa, Middle East or Eastern Asia
	__Africa
__Educates teams of professionals at country of origin	__China
__Educates teams of professionals at organization's home country	__India
__Educates individual professionals at country of origin	__Pacific Rim, South East Asia
__Educates individual professionals at organization's home country	__Australia or New Zealand

Organization type (Mark the two most appropriate, one in each column):

____ 501 c3 organization	____ Humanitarian aid organization (NGO)
____ Not for profit organization	____ Hospital
____ For profit organization	____ Clinic _ Other: ____________________

Organization web site: _______________________________

Organization address line 1: ________________________________

Organization address line 2: ________________________________

Organization city: _________________________ Organization country: _________

Organization state/province: ________________ Organization postal code:_____

Org main phone country code: ___ Org main phone: _________________Ext____

Organization fax country code: ___ Organization fax: ________________________

Organization year established: ____ Org information email: _________________

Once you are published on the WHF Web, details should be revised / completed by the Data Manager.