EARL Accreditation Enrollment Online Form – EANM EARL

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Name

This field is for validation purposes and should be left unchanged.

Institution name in English(Required)

Please ensure you write the name in English, it will be displayed on the accreditation certificate.

Department name in English(Required)

Please ensure you write the name in English, it will be displayed on the accreditation certificate.

Address of institution in English:(Required)

Street & number

City

Post code

Country

EU VAT number (billing)

Billing details

same as institution/department

different from institution/department

Billing details

(if different from institution/department)

Entity name in English:

EU VAT number (billing)

Street & number (billing)

City (billing)

Post code (billing)

Country (billing)

Select the check box for each contact below if you wish this person to receive notifications for QC due

Full name and email of person completing this form(Required)

Contact Email(Required)

Email of person completing this form

Head of Department title & full name(Required)

Receive QC requests

Email(Required)

Phone

Primary contact for EARL accreditation full name(Required)

Receive QC requests

Email(Required)

Phone

Contact for scanner validation full name(Required)

Receive QC requests

Email(Required)

Phone

Other contact(s) to receive QC requests

Name(s)

Email(s)

PET/CT | PET/MR System 1

Select scanner type(Required)

PET/CT

PET/MR

Brain PET

Manufacturer(Required)

Model/Version(Required)

Scanner Software Version(Required)

Time of flight(Required)

Yes

Resolution recovery, PSF reconstruction „HD(Required)

Yes

Number of CT slices(Required)

Device Serial Number(Required)

Choose accreditation(s)(Required)

¹⁸F standard 1

¹⁸F standard 2

⁶⁸Ga

⁸⁹Zr

¹⁸F/¹¹C Brain PET/CT

¹⁸F/¹¹C Brain Calibration only

Select quarter when you want the harmonization to start(Required)

Add Another PET/CT PET/MR

PET/CT | PET/MR System 2

Select scanner type(Required)

PET/CT

PET/MR

Brain PET

Manufacturer(Required)

Model/Version(Required)

Scanner Software Version(Required)

Time of flight(Required)

Yes

Resolution recovery, PSF reconstruction „HD(Required)

Yes

Number of CT slices(Required)

Device Serial Number(Required)

Choose accreditation(s)(Required)

¹⁸F standard 1

¹⁸F standard 2

⁶⁸Ga

⁸⁹Zr

¹⁸F/¹¹C Brain PET/CT

¹⁸F/¹¹C Brain Calibration only

Select quarter when you want the harmonization to start(Required)

Add Another PET/CT Pet/MR Form

Add Another PET/CT PET/MR

PET/CT | PET/MR System 3

Select scanner type(Required)

PET/CT

PET/MR

Brain PET

Manufacturer(Required)

Model/Version(Required)

Scanner Software Version(Required)

Time of flight(Required)

Yes

Resolution recovery, PSF reconstruction „HD(Required)

Yes

Number of CT slices(Required)

Device Serial Number(Required)

Choose accreditation(s)(Required)

¹⁸F standard 1

¹⁸F standard 2

⁶⁸Ga

⁸⁹Zr

¹⁸F/¹¹C Brain PET/CT

¹⁸F/¹¹C Brain Calibration only

Select quarter when you want the harmonization to start(Required)

Add Another PET/CT Pet/MR Form

Add Another PET/CT PET/MR

PET/CT | PET/MR System 4

Select scanner type(Required)

PET/CT

PET/MR

Brain PET

Manufacturer(Required)

Model/Version(Required)

Scanner Software Version(Required)

Time of flight(Required)

Yes

Resolution recovery, PSF reconstruction „HD(Required)

Yes

Number of CT slices(Required)

Device Serial Number(Required)

Choose accreditation(s)(Required)

¹⁸F standard 1

¹⁸F standard 2

⁶⁸Ga

⁸⁹Zr

¹⁸F/¹¹C Brain PET/CT

¹⁸F/¹¹C Brain Calibration only

Select quarter when you want the harmonization to start(Required)

EARL Accreditation enrollment form

Billing details

PET/CT | PET/MR System 1

PET/CT | PET/MR System 2

PET/CT | PET/MR System 3

PET/CT | PET/MR System 4