Investigator Application Form | ReSolution Latin America

ABOUT US

/ INVESTIGATOR APPLICATION FORM

* ALL QUESTIONS CONTAINED IN THIS FORM ARE STRICTLY CONFIDENTIAL AND FOR INTERNAL RESOLUTION USE ONLY.

ABOUT US / INVESTIGATOR APPLICATION FORM

* ALL QUESTIONS CONTAINED IN THIS FORM ARE STRICTLY CONFIDENTIAL AND FOR INTERNAL RESOLUTION USE ONLY.

Name* :

Title (e.g.- Dr, Mr., Ms. etc.):

Institution/Hospital* :

Type of institution* :

PrivatePublic

Practicing Physician*:

YesNo

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)* :

THANKS FOR SUBMITTING THE FORM!

NAME* :

Title (e.g.- Dr, Mr., Ms. etc.):

Degree (Tick all that apply):

Other (please specify):

Institution/Hospital* :

Type of institution* :

PrivatePublic

Practicing Physician* :

YesNo

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)* :

THANKS FOR SUBMITTING THE FORM!

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