Research Investigators Source

Please fill out and submit the following form. You will be asked to fill out an additional form describing your Therapeutic Areas of Expertise.

Name of Organization:
Address:
City:
State or Province:
Zip Code:
Telephone Number:
Fax Number:
E-Mail:

Clinical Research Experience: (in years):
Preferred Phase(s) of Clinical Research: (Multiple Selection Allowed)	Phase 1 Phase 2 Phase 3 Phase 4
Specialty Area(s) of Practice:

Study Coordinator:
Coord Telephone Number:
Study Administrator:
Adm Telephone Number:
Person Completing Form:

Please fill out the above enrollment form. The fee for a Facility Membership is $425 U.S. dollars.
We accept Visa, Mastercard or payment by check. If you have questions or would like to register by telephone, call (800) 535-6365.
Thank You

Please click on the NEXT button. You will be asked to fill out an additional form describing your Therapeutic Areas of Expertise. Please Print and Save both pages and fax them to 763.544.1415.