2008

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Identity
First Name  Middle Initial
 
Last Name  Degree
 
Date of Birth (MM/DD/YYYY)  SSN (#########)
 
Country of Citizenship  Gender
  Male Female
Ethnicity  Email Address
 

Office contact information after July 16, 2008
(Use home info if office is not applicable.
If info is not known, skip to the next section.)
Office Address (Line 1)        Daytime Phone #1
      
Office Address (Line 2)        Phone Extension
      
City        Fax Number
      
State     Email Address
   
Zip Code
UCSF Box #

Office contact information before July 16, 2008
(If different from above.)
Office Address (Line 1)        Daytime Phone #1
      
Office Address (Line 2)        Daytime Phone #2
   
City     Fax Number
   
State        
       
Country
Zip Code
UCSF Box #

Information about you pertaining to the time the program begins on July 29, 2008
Institutional Title
Institution
UCSF UC Berkeley Stanford
Other:
School
Department
Division
Research Interest
      

Information regarding your research advisor
Name
Institution
UCSF UC Berkeley Stanford
Other:
School
Department
Division
      
Information regarding a second research advisor
Name
Institution
UCSF UC Berkeley Stanford
Other:
School
Department
Division

For which courses are you applying?
  Course Title
UCSF & UC Berkeley fellows, faculty & staff
No UC affiliation
Choose only one DCR offering:
Designing Clinical Research (Epi 202)
OR
Designing Clinical Research for Residents and Students (Epi 150.03)
$1100
$2200

Responsible Conduct of Research
$350
$700

Building a Career in Clinical Research
$350
$700
If you choose all 3 courses the price is reduced
$1650
$3300
      
Payment information
Will any portion of your fees be paid by a UCSF account or department?
Yes       No

Is there any other information relevant to your application which we should know?

Commitment
(Experience has shown that requiring this in advance makes things work better all around):
I promise to attend all the sessions (unless I pre-arrange with my section leader to be absent for a single week) and to do all the homework ontime. Agree