Investigator Sign-Up Form

Please read carefully.

By filling out and submitting the form below, I agree that the information I provide will be added to a global clinical trial investigator database. I understand and permit the use of my personal information for this purpose and further understand that the information I provide may be reviewed for consideration as part of an existing or upcoming clinical trial. Finally, I understand that the information that I provide may be disseminated to third parties when necessary, including but not limited to: sponsors of clinical trials, applicable regulatory agencies and other associated subsidiaries and affiliates of Clinsys.

Fields marked with ( * ) are required.

Section 1: Investigator Information

Last name: ( * )

First name: ( * )

Degree: ( * )

Site/institution: ( * )

Street address: ( * )

City: ( * )

State/province: ( * )

Zip: ( * )

Country: ( * )

Phone: ( * )

Fax: ( * )

Email: ( * )

Section 2: Primary Contact Information for Site/Facility

Last name: ( * )

First name: ( * )

Title: ( * )

Site/institution: ( * )

Street address: ( * )

City: ( * )

State/province: ( * )

Zip: ( * )

Country: ( * )

Phone: ( * )

Fax: ( * )

Email: ( * )

Section 3: Specialties

(please select all that apply) ( * )

The Specialty:

Section 4: Facility Setting

(please select the most accurate) ( * )

The type of facility: ( * )

Section 5: More Information

How many years of clinical research experience does the principal investigator have? ( * )

Which phase(s) of clinical research does the principal investigator have experience in?
(please check all that apply) ( * )

Have you been audited by Regulatory Authorities? ( * )

Yes

If yes, when was the audit?

Have you been audited by a sponsor? ( * )

Yes