Thank you for your interest in the 
Regulatory and Reimbursement Services. Please use this form to provide information about your company and solution. ALL questions require a response.

For more information, contact Nicole Häusler (n.haeusler@engage-ventures.com) or Björn Hackbarth (b.hackbarth@engage-ventures.com).

Eligibility criterion: SME with headquarters in Europe*

IMPORTANT: 
Typeform is very cool BUT does not let you save and finish your application later. So we highly recommend saving your responses in a separate word document. Just in case.

*Albania • Austria • Belgium • Bosnia & Herzegovina • Bulgaria • Croatia • Cyprus • Czech Republic • Denmark • Estonia • Finland • Former Yugoslav • Republic of Macedonia • France • Germany • Greece • Hungary • Iceland • Ireland • Israel • Italy • Latvia • Liechtenstein • Lithuania • Luxembourg • Malta • Montenegro • Netherlands • Norway • Poland • Portugal • Romania • Serbia • Slovakia • Slovenia • Spain • Sweden • Switzerland • Turkey • UK
Start
 
You and your company

 
Company name *

 
First name *

 
Last name *

 
Job Title *

 
Phone *

Starting with the international dialing code.
Example : 0033 for France.
 
Company headquarters (Country) *

 
Company website *

 
Company Logo

 
Company Twitter

 
Company LinkedIn

 
Year the company was founded *

 
Number of employees *

 
Brief description of your product/service *

Short description of product/service with emphasis on uniqueness of the business
 
Your regulatory and reimbursement challenge

 
* Regulatory challenge


 
* Reimbursement challenge


 
* Specify your current regulatory and reimbursement challenge

Please elaborate on your challenge and specify the countries in which you need our support.
 
Data protection *

We do hereby inform you that the data you have sent us by way of this electronic form shall be included in the information systems of TicBiomed as eHealth Hub project coordinator. Said communication shall be used to deal with your request, as well as to send any information which may be of interest to you about the project activity. By indicating your data, and pursuant to the stipulations of article 6 of the L.O.P.D., you are granting your clear consent to TicBiomed, Tecnologías de la Información de la Región de Murcia to process, in compliance with the purposes mentioned in the previous paragraph above, the personal data provided up to three years after the project end. Notwithstanding, at any time you may exercise your rights of access, rectification, objection and, where applicable, cancellation, at the address: CEEIM, Campus Universitario de Espinardo, 7, Espinardo, 30100 MURCIA or at the e-mail: lopd@ticbiomed.org
     
 
I give eHealth Hub permission to publish the videos and photographs taken in their events *

     
Thank you for your registration! We will contact you.
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