SCRI-CSU Advanced Clinical Trial Workshop on
“Managing Large Investigator-Initiated Trials”
2 April 2015, Thursday
REGISTRATION FORM
Title: ProfAssoc ProfAsst ProfDrMrMs / Address:*Surname: / Contact No.:
*Name: / Mobile No.:
Designation: / Fax No.:
Department: / **Email:
Institution: / MCR No.:
*Name as given in the registration form would be reflected in the certificate of attendance.
**Please enter a valid email address. Confirmation of registration will be sent to your email account.
Registration
I would like to register for SCRI-CSU Advanced Clinical Trial Workshop on “Managing Large Investigator-Initiated Trials”- 2 April 2015 (limited to 6 projects only)
Please provide the following information:
Research Project Title:
Therapeutic Area:
Grant Amount:
Grant Funding Agency:
Protocol No. (If applicable):
NOTE:
· Participants are required to submit their draft protocols by 2 March for SCRI to screen through and assemble the required number of facilitators for the small group discussions.
· Free registration on a first-come-first-served basis. Please submit your CV via csxchange.sg.
Signature: Date:
Please mail the original registration form to the address stated below.
Closing Date: 2 March 2015, Monday. Free registration on a first-come-first-served basis.
For enquiries, please contact
The Secretariat, Clinician Scientist Unit (CSU), NUHS Leadership in Academic Medicine (NLAM) Program
Dean’s Office, Yong Loo Lin School of Medicine, National University of Singapore
1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore 119228
Attn: Ms April Sim, Tel: (65) 6772 7562, Fax: (65) 6778 5743, Email:
Or Ms Cindy Chen, Tel: (65) 6772 3819, Fax: (65) 6778 5743, Email:
Cancellation Clause:
Any cancellation or replacement must be conveyed to the Organiser in writing by 2 March 2015.
A cancellation charge of $100 will be levied if the cancellation is received after 2 March 2015.
The Organiser reserves the right to cancel the workshop should unforeseen circumstances necessitate it.