Application for Membership Applicant Name:(required) Organization name and address:(required) Applicant email address:(required) Select the category that best describes your organization or status as an individual:(required) Not-for-profit organization For-profit company/organization (pharmaceutical corporations contract research organizations core laboratories and technology companies) Individual (cardiac safety consultants advisers academics individuals from regulatory agencies) Briefly describe your organization or your role as an individual interested in cardiac safety: Briefly explain your interest in CSRC: Explain your planned contribution to CSRC (check all that apply):(required) Financial: In the box below indicate monetary amount of the contribution and justification for any variance. Data: In the box below describe whether you have access to and permission to share data with the consortium. Expertise: In the box below describe the expertise you plan to bring to the work of the consortium. Technology: In the box below describe any technology you plan to bring to the work of the consortium Other: Describe in the box below. Please send CVs/resumes of the individuals who will be participating in the CSRC to CardiacSafety@dm.duke.edu. Ensure that each CV/resume includes the individual's name and email address. Use subject: CSRC Membership Application.