OBSERVER REGISTRATION

Name*
First Last
Address*
City*
State*
Zip*
Country*
Email*
Work Phone*
Cell Phone*
Do you have any website of your practice?*
- Yes
- No
How many years in practice?*
Do you have hospital affiliations?*
- Yes
- No
Academic Appointments*
Specialty*
Board certifications*
Will you be able mentor students for one month rotation?*
- Yes
- No
[This includes student shadowing you in your office]
Will you be able to mentor them in Clinical Research?*
- Yes
- No
Publications*
Mentoring in clinical research should result in a publication in a peer reviewed journal