Membership Application or Renewal

Applicant Name: Employee ID #: Date of Application:

Academic Title: Degree(s): Department:

Phone: Fax: Mail Code: E-mail address:

A. Please indicate the primaryScientific Research Program in which you would like to (or already) participate(this section is not required forClinical members):

Development and Cancer – Targets the nexus between developmental biology, genetics, and tumorigenesis, and enhances scientific interactions between clinical investigators and laboratory scientists.

Cancer Cell Networks – Promotes investigation that will lead to a mechanistic understanding of aberrant cell regulatory networks supporting tumor initiation and progression.

Chemistry and Cancer – Focuses on the design and use of small drug-like molecules and associated molecular probes to discover, interrogate, and target biological pathways relevant to cancer.

Experimental Therapeutics – Helps identify, promote, develop, synergize, and exploit UTSW discoveries throughout the Cancer Center with preclinical models and early-phase clinical trials to provide new, mechanism-based therapies for human cancer.

Population Science and Cancer Control – Studies the social and behavioral aspects of cancer prevention, detection, and treatment, and generates research discoveries addressing cancer burden and disparities in UTSW’s North Texas catchment area.

B. Please indicate the Disease-Oriented Team in which you would like to (or already) participate:

Breast Gastrointestinal Genitourinary Gynecologic Head & Neck Hematologic Lung

Neurologic Pediatric Phase I Trials Population Science Radiation Oncology Sarcoma/Melanoma

C. Please provide a short narrative description of your research and/or clinical interests as they relate to cancer (use additional page if needed):

D. Do you expect to use any of the Simmons Cancer Center Shared Resources and/or Institutional Core Facilities in the next year?(This is not a binding commitment) Yes No

Cancer Center Institutional




Research Office

High-Throughput Screening
Live Cell Imaging

Small Animal Imaging

Tissue Management

Electron Microscopy

Flow Cytometry


Mouse MRI

Molecular Pathology

NextGeneration Sequencing

Protein Chemistry Technology


Rapid Biochemical Kinetics

Structural Biology

Synthetic Chemistry



Suggestions for new Shared Resources:

E.Professional Credentials: Please submit your current NIH biosketch with this application.

Please return this form electronically to: or

For more information about the Simmons Comprehensive Cancer Center and its programs,

please visit the website: