OBSERVER REGISTRATION Name* First Last Address* City* State* Zip* Country*USAEmail* 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