Center for Cancer Metabolism Membership Application

Name (First, Middle, Last)*

Title*

University (if external to Ohio State)

College

Department

Division

Email*

Phone Number*

Office Street Address

Street Address

Street Address Line 2

CityState

Zip Code

Room Number

Administrative Assistant (if applicable)

Admin Email

Admin Phone Number

List any actively funded research projects related to cancer metabolism (federal, foundation, corporate, etc.). These include funding as a PI or as a collaborator.

List active clinical trials in cancer metabolism and your role.

List any cancer metabolism projects you will be developing in the next two years.

If you are new to cancer metabolism research and/or have a desire to join the CCM as an interdisciplinary collaborator (e.g., you have no applicable research for questions 1-3), please describe your specific expertise and how you plan to utilize it in Cancer Metabolism – focused research. Please list here all members of the CCM you are planning on or wish to collaborate with.

Please attach a copy of your current NIH Biosketch or CV.*

Application and copy of current NIH Biosketch or CV will be submitted to the Center for Cancer Metabolism administration. All applications will be reviewed on a weekly basis. All applicants will receive a formal notice of the committee’s decision after the review.

Sender Name

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Questionnaire