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Cancer Center Membership Application

Cancer Center Membership Application

First Name
Last Name
Title
Telephone
Fax
Email

Your Webpage

College
Department/Division
Street:
City
Zip

RESEARCH PROGRAMS (Please select one as your primary program)

Carcinogenesis and Chemoprevention

Cancer Targets, Therapeutics & Imaging

Cancer Cell Signaling  

Population Behavior, Health and Outcomes


ORGAN SITE FOCUS (Check any that apply)

Bone/Soft Tissue

Hematologic

Brain

 Liver

Breast

 Pancreas

Childhood

 Skin/Melonoma

Colorectal

 Lung

Gynecologic

 Urologic/Prostate

Head & Neck

 

 Other:  

                                                  

CLINICAL TRIALS FOCUS (Please Specify)

 

 

POPULATION HEALTH BEHAVIOR AND OUTCOMES(Check any that apply)

Behavioral Risk Factors

Quality of Life and Cancer Survivorship

Screening/Early Detection

Outcomes/Health Services Research

Epidemiology

Health Disparities

 Other (please specify):   

 

COLLABORATIONS

Please list the names of active and recent collaborators at UIC and/or University of Illinois Urbana-Champaign (cancer researchers and/or clinicians).  Please limit to 250 characters.

CANCER RESEARCH/CLINICAL INTEREST

Please provide a few sentences that summarize your current cancer research and/or clinical interest. This information will be included on your individual profile page on the Cancer Center Website. Please limit to 250 characters.

BIOSKETCH and HEADSHOT PHOTOGRAPH

Your application cannot be processed without a copy of your biosketch and a headshot. Please email both the biosketch and the image to: rschwind@uic.edu. An NIH biosketch form can be downloaded, please click here.

  YES, I have emailed my biosketch, as requested. 
        Please leave these fields blank:    

CREDENTIALS

Please list terminal degrees(s) (MD, PhD, or others) 

 



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