Membership Application

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:

Other Investigator Names & Email Addresses

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

Our institution has a dedicated clinic for scleroderma:

Mailing Address:

Mailing Town/City:

Mailing Country

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

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

If yes, please provide links of 1-3 publications below:

Should your Institution wish to have the initial ($250 USD) and annual ($200 USD) dues waived, please express that here and reasons why you feel they should be waived. The waiving of dues is considered on a case by case basis and will be reviewed on a yearly basis.