WORLD HEALTH ORGANIZATION

CH - 1211 GENEVA 27 - SWITZERLAND

Application for a licence to use the ICF codes in a product that is to be sold / licensed

Company Name :
Parent Company :
Address :
City : / State : / Post Code :
Country :
Web site : /
Contact Person : / Title :
Tel : / Fax :
E-mail :

I confirm that the information submitted as part of my application is accurate and complete to the best of my knowledge. I agree to notify the World Health Organization if this information changes.

Signature : Title :

Name in Full : Date :

Please post or fax the completed application to :

Mr Ian Coltart
Permissions and Licensing
Information Management and Dissemination
World Health Organization
20, Avenue Appia
CH-1211 Geneva 27
Switzerland
Tel: +41 22 791 3822
Fax: +41 22 791 4806
Description of intended use

WHO is able to license the use of the electronic versions of the ICF codes in the following languages :

Arabic

Chinese

English

French

Russian

Spanish

Please indicate which of the above language versions you wish to license.

Which of the following formats will you use for distribution of your product (Please tick where appropriate)
Magnetic Media Optical Media Internet Other (Please explain)
Name(s) of the product/s to be included in the licence :
Please describe the features of each product, the concept of the product and how it is intended to be used :
How do you propose to use the ICF codes and descriptions in the product/s and how many of the codes and descriptions will you use ? How will the codes be made available to the users ?
What added value does your product offer to users of ICF ?
Does your software provide data validation ie the ability to provide specific diagnosis information on the basis of sex and age ?
Scope of Licence
Names of countries where the product/s will be distributed :

Describe the target market for your product/s.

Please provide additional information on how your product/s will be priced and it will be sold / licensed to users. Please indicate the price in each case, and whether this is per user, per CPU or another category.
Expected annual sales volume / numbers of users (approximate) :
What is the target distribution date ? If currently distributed, please give initial date of distribution :
Are you planning to distribute your product through indirect sales channels ? If yes, please provide additional information on the channels to be used.
If your product is to be distributed via the internet please include details of how you propose to use this to medium to distribute your products eg online download, online access to services etc.
Does your web site carry any form of advertising ?
Yes No If yes, please provide more details.

How will you control access to the product and what levels of security does your web site offer ?

Please provide a summary of your company's activities ?

ICF 2004