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EDDNAL Laboratory registration form

EDDNAL Laboratory Registration form

Please complete this page, should your laboratory be engaged in research.

Person completing this form
Name of Laboratory
Name of Institution
Head of the Laboratory
Degree(s):
Field/Speciality
Email
Phone
Fax
Complete Mailing Address
Lab URL (if lab has a web site)

Is your laboratory certified by an official organisation in your country that allows you to perform mutation analysis? YES
NO
If YES, by which one?

II

Contact Name 1
Degree(s)
Field/Speciality
Email
Phone
Fax
Contact Name 2
Degree(s)
Field/Speciality
Email
Phone
Fax

III

1. Disease Name(s)/Abbreviation(s):
Gene(s)/Locus(i):
OMIM#
2. Please give a brief description of your research
3. Citations relevant to your laboratory's research on this disease:(MUST include first author last name/initials, full journal name, volume, page, year)
4. Would you be interested in receiving DNA samples from patients affected with this (these) disease(s) on a research basis? YES
NO

EDDNAL 2016