AffiliateIndDataSheet040517

WHF Individual’s Data Sheet

*Individual’s Name: ________________________________ (*Underline=required) Rev 5/17/04

*Individual’s Data Manager: _______________________ Title: __________________

*Phone: ___________________________ *Fax: _______________________________

*E-mail: ___________________ *City, State / Prov: __________ *Country: _____

Individual’s Contact Person 1: _______________________ Title: __________________

Phone: ______________________________ Fax: _____________________________

E-mail: ______________________________________

Individual mission statement on back/separate sheet (< 360 characters and spaces, Ind. Name at top):

Individual’s focus (Mark your sixmost 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 most important regions of interest
__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

Individual’s web site: _______________________________

Individual’s address line 1: ________________________________

Individual’s address line 2: ________________________________

Individual’s city: ____________________ Individual’s country: ________________

Individual’s state/province: _____________ Individual’s postal code: __________

Ind. main phone country code: ___ Ind. main phone: _______________Ext______

Individual’s fax country code: ___ Individual’s fax: ________________________

Individual’s birth year:_____ Ind. information email: ______________________

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