World Allergy Organization

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Application To Host GLORIA

All information received on this form is confidential.
Date of application:
Name of WAO Member Society hosting the meeting:
WAO Member:
Position within the Member Society:
Address:

City:
State/Province:
Postal Code:
Country:
E-mail:
Telephone:
Fax:
Indicate the year for which you are seeking a GLORIA Symposium:

Please rank your preference of GLORIA Module to host at your meeting
	Module 1 - Allergic Rhinitis
	Module 2 - Allergic Conjunctivitis
	Module 3 - Allergic Emergencies (Acute Asthma, Angioedema, Anaphylaxis)
	Module 4 - Immunotherapy
	Module 5 - The Treatment of Severe Asthma
	Module 6 - Food Allergy
	Module 7 - Angioedema
	Module 8 - Anaphylaxis
	Module 9 - Diagnosis of IgE Sensitization
	Module 10 - Chronic Rinosinusitis and Nasal Polyposis
	Module 11 - Drug Allergy
	Module 12 - Urticaria
Name of society meeting:
Dates of society meeting:
Site/location:
Objectives/purpose of meeting:
The following information is optional and not required for application. What percentage of your anticipated attendees will fall into the following categories?
a. Allergists
b. Other Health Care Professionals
	Please specify:
What is the primary language of your Congress? (The GLORIA program materials are produced in English.)
Please confirm that you are able to download and print materials locally.			Yes No
Scientific program topics:
Please select three choices of GLORIA faculty to present at your meeting.
Proposed speaker:		1.
		2.
		3.
Anticipated attendance at society meeting:
Anticipated attendance at GLORIA symposium:
Website address for the meeting:
When will the preliminary/final program be available?:
By submitting this completed form on behalf of my WAO Member Society, I agree to honor the Member Society's Role as stated on the first page of the application.

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