Application for Membership

Part 1 - General Information 

Full institution name, including affiliated medical school (if any):*
Coordinating Investigator Name:*
Coordinating Investigator Email Address:*

Other institutional investigators and their e-mail addresses:

Investigator Name 1:
Investigator Email Address 1:
Investigator Name 2:
Investigator Email Address 2:
More institutional investigators?
Investigator Name 3:
Investigator Email Address 3:
Investigator Name 4:
Investigator Email Address 4:
Investigator Name 5:
Investigator Email Address 5:
Investigator Name 6:
Investigator Email Address 6:

Part 2 – Please complete the following regarding criteria for full membership.

Our institution has a dedicated clinic for scleroderma.
Full Mailing Address:*
Our clinic has participated in at least one clinical trial of direct relevance to scleroderma.*
Please list the clinical trial(s) (Including sponsor) in which you/your institution has participated
Our clinic has participated in a previous clinical trial for a non-scleroderma immunologic or rheumatological disease.
Our clinic has available support personnel experienced in clinical trials and “good clinical practices”.
Our clinic has the ability to recruit patients with scleroderma for clinical trials.*
Our institution has published at least one manuscript within the last five years describing clinic aspects of scleroderma.*
Please list the manuscript information:
Should your institution wish to have the initial ($250 USD) and annual ($200 USD) dues waived please express that here, and why. The waiving of dues is considered on a case by case basis and will be reviewed on a yearly basis.
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