SFRD Expert Patient Organization (EPO) - Partnership & Onboarding Form

Section A: Organizational Identity & Contact Information

Welcome to the SFRD National Alliance. This section captures your organizational identity so that we can collaborate effectively.

Legal Name of the Organization *

Date of Incorporation *

Registration Number *

PAN Number *

Official Website URL

Annual Event / Observance Day *

Select Day and Month

Mission Statement *

Vision Statement *

Social Media Handles *

Add links to your primary social channels. At least one handle is required.

Registered Office Address

Country *

State *

City *

Pincode / Postal Code *

Address Details (Street/Building) *

Official Contact Email *

Official Contact Phone *

Section B: Legal & Structural Information

This information helps us understand your legal status and governance structure for partnership compliance.

Type of Organization *

Tax Exemption Status

12A80GFCRANot Applicable

Key Office Bearers *

Please provide details for at least three primary contact persons (e.g., President, Secretary, Founder).

Office Bearer 1

Name

Designation

Phone

Office Bearer 2

Name

Designation

Phone

Office Bearer 3

Name

Designation

Phone

Section D: Partnership Consent & Agreement

This agreement confirms our shared commitment to the rare disease community. An authorized representative must complete this section.

I confirm that I am an authorized representative of the organization named in this form.I understand that this partnership is voluntary and collaborative. We can choose to end our association at any time by providing written notice.I consent to SFRD securely storing our organization's information and listing us in its public directory of trusted EPO partners.Mutual Patient Referral & Confidentiality: We agree to adhere to a mutually agreed-upon protocol for patient referrals, ensuring patient consent and strict confidentiality for all shared data.By checking this box, I confirm that all the information provided is accurate to the best of my knowledge and agree to the terms of this partnership.

Full Name of Authorized Representative *

Designation *

Date

Digital Signature *

SFRD Official Use Only

This section is optional and can be completed by SFRD staff during onboarding.

Date of Onboarding

Staff Responsible

Verified Document Checklist

By-laws MoA AoA

Remarks

Unique Expert Identifier PIN

Your permanent identification number in the SFRD framework.

SFRD Expert Patient Organization (EPO) - Partnership & Onboarding Form

Section A: Organizational Identity & Contact Information

Registered Office Address

Section B: Legal & Structural Information

Key Office Bearers *

Section C: Scope of Work & Expertise

Collaboration Preferences

Section D: Partnership Consent & Agreement

SFRD Official Use Only