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Membership Application Form

* Required
First Name: *  
Initial:        
Last Name: *  
Degrees held:


Title:                       
Employee ID:            *  
Personal URL:           
Primary Department:
School:                    
Office Address:          *  
City:                        
State:                      
Zip Code:                
Phone:                     *  
Fax:                        
Email:                      *  

Area of Clinical Interests or Research Interests: (Please provide a brief description of your research interests. Please highlight the cancer relevance of your research, if it is not obvious).
Collaborations: (Please list all active and recent collaborations with other Emory University cancer researchers and clinicians).

Program Selection:




Primary Program:    
Secondary Program:

Funded Research/Training Grants:
Are you the Principal Investigator (PI) in any cancer-related funded research projects? If yes, are any peer-reviewed?
Are you a co-investigator or collaborator on any cancer-related funded research projects? If yes, are any peer-reviewed?
Clinical Trials Involvement:
Have you enrolled patients onto cancer clinical trials in the past year?
If yes, how many of those patients have been registered under your name on cancer-related clinical trials over the past year?

 Institutional     Cooperative Group    Industry  
Cancer-Related Publications:
Do you have any peer-reviewed cancer-related publications (2001-present)?
If yes, indicate on your CV or on another page, which publications (2001 to present only) are cancer-related.

Required Documents:
PLEASE UPLOAD THE MOST CURRENT COPY OF YOUR FOUR-PAGE NIH BIOSKETCH AND MOST RECENT CV AND OTHER SUPPORT PAGES TO THE APPLICATION.
NIH BIOSKETCH:
CV:
Winship Shared Resources:
Which Winship Cancer Institute Shared Resource would you potentially use?





Please describe any shared resources that are not currently part of the Winship Cancer Institute that you feel would benefit your research.

The NCI guidelines require that new membership in the Winship Cancer Institute is reviewed at the time of application and again annually thereafter. While we annually request some information from you directly(such as biosketches, web updates, etc.), we also have the ability to obtain some data from our central University data sources. From these systems we obtain information regarding your cancer-related grant activity and effort reports for cancer-related grants and clinical trials. This information does not include salary data. Obtaining this information centrally reduces the amount of information we need to obtain from you personally. Acceptance of membership in Winship indicates your willingness to allow us to access this information on your behalf. Please contact Susannah Conroy (sconroy@emory.edu, 404-778-2218) if you have any questions.

I have reviewed the Winship Cancer Institute Membership Guidelines and agree to follow these guidelines as well as actively participate in the further development of the Winship Cancer Institute.

Signature:       Date:


(Please fill in all the Required Fields)