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Membership Form

Membership Form

Vitiligo International Patient Organizations Committee Form
Hosted by VIPOC
10 rue Lacuée 75012 Paris, France

To support in being informed about the objectives and actions of the VIPOC Committee and Conferences (mentioned in your choices below):
Checkboxes
First Name 
*
Last Name 
*
Organization Name
Type of Organization
Organization Address
Legal rules applicable to organization
Official Registration office
Official registration date
Registration Number
Registration Office Address
Phone 
*
Website URL
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Twitter
Instagram
LinkedIn
Organization Description and Activities
Email address 
*
Message 
*
Logo 
*
Choose file Upload the official logo of your organization
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