Investigator Application Form

* All questions contained in this form are strictly confidential and for internal ReSolution use only.

Name (Last, First):
Title (e.g.- Dr, Mr., Ms. etc.):
Degree (Tick all that apply): M.D. Ph.D MBA Pharm. D. R.N. Other (please specify):
Institution/Hospital:
Type of Institution: Private Public
Practicing Physician: Yes No
Address 1:
Address 2:
City: Zip Code: Country:
Telephone:
Email: Fax:
Cell Phone:
THERAPEUTIC SPECIALIZATION
Therapeutic Area(s): (e.g. - oncology, infectious disease):
Sub-specialization (e.g. – pancreatic cancer, HIV):
1.
2.
 
3.
Other (please specify):
Comments (please feel free to include any relevant comments):  
CLINICAL TRIAL EXPERIENCE
Previous Clinical Trial Experience:
Phase:
Number of Trials:
Phase I:
Phase II:
Phase III:
Phase IV:
Comments (please feel free to include any relevant comments):  
I hereby agree that ReSolution may keep my details on file and contact me with possible relevant opportunities.