IPOPI NMO Support Programme Application The IPOPI NMO Support Programme is open to all NMOs and serves as a resource to support initiatives that enhance diagnosis and treatment for primary immunodeficiency patients, as well as to help new associate NMOs to become effective organisations. Question Title * 1. Name of the organisation (NMO) Question Title * 2. Country of the NMO Question Title * 3. Name of the NMO Question Title * 4. Name of chairperson of the NMO Question Title * 5. Do you represent: A full NMO An associate NMO Question Title * 6. Your name Question Title * 7. Email address Question Title * 8. Phone number Question Title * 9. Project description Briefly describe your project (outline the project goals, timeline, participants, starting and finishing dates, etc). Question Title * 10. Project budget Please insert a short budget statement of your initiative with all the amounts shown as EURO (€). Question Title * 11. Amount requested from IPOPI’s programme in EURO (€):Please note that each project can receive a maximum grant of €5,000. Question Title * 12. Have you explored alternative funding options to develop this project?Select one of the options. Yes, we have looked into alternative funding and have secured a co-funder Yes, we have looked for alternative funding, and were not granted No, we have not looked yet, but will search in complement to this application Question Title * 13. If you selected "Yes, we have secured a co-funder," kindly identify the co-funder Question Title * 14. I confirm that the contents of this application are true to the best of my knowledge Yes No Question Title * 15. Please write your full name and today's date. Done