Membership Application

Before submitting your application, carefully review the center's membership requirements. Application for membership is voluntary. By submitting this application, you are indicating fulfillment of the center's membership requirements and agreement with the center's basic objectives.

As you complete this form, be sure to fill out all required fields (indicated by an asterisk) and to attach all required documents. Once you submit your application, it will be reviewed by the relevant program area director(s) as well as the center's leadership team. If you have questions, contact us.

Name: *

Title:

Organization: *

Address 1: *

Address 2:

City: *

State: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip: *

Phone:

Email: *

Membership Type: *

Academic

Commercial

Areas of Interest (select all that apply)

Basic Research:

Computational Biology

Microarray Analysis

Proteomics

Phenotyping

Translational Research:

Pharmacogenomics

Microarray Diagnostics

Microarray Therapeutics

Services:

Secure and HIPAA-protected Data

Biological Specimen Storage and Tracking

High-performance Computational Facilities

High-availability data storage

Web-based Protocol Management

Commercialization Core:

Access to Venture Capital

Initial Project Information

Title: *

Sponsor:

Collaborator(s):

Short Description: *

Long Description: *

Attach a Microsoft Word or text file (.doc, .rtf, .txt) that describes the scientific origins and objectives of the project, as well as the project's commericalization potential. No more than eight pages, please. (Maximum 1MB)

Questions/Comments:

Type questions about the center and/or any additional information about you or your interest in the center.

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