Membership Application Form

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?

Yes

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.

Yes

Full Mailing Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

Our clinic has participated in at least one clinical trial of direct relevance to scleroderma.*

Yes

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.

Yes

Our clinic has available support personnel experienced in clinical trials and “good clinical practices”.

Yes

Our clinic has the ability to recruit patients with scleroderma for clinical trials.*

Yes

Our institution has published at least one manuscript within the last five years describing clinic aspects of scleroderma.*

Yes

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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