[email protected]
Home
About
Bylaws
Executive Committee
Members
Membership Application
Membership Application Form
Newsletter
Rodnan Skin Score Training
Meetings
Publications
Industry
Rountable
Site Infrastructure Database
Working Groups
Calcinosis
Cardiac
Damage & Activity Index
Gastrointestinal
Juvenile Scleroderma
Lung Disease
Renal Crisis
Skin Disease
Vascular
Definitions Of Disease Onset & Organ Involvement
Grants & Awards
Working Group Grants
Betty Z. Benedict Award
Visiting Fellowships
Travel Awards
Support Us
Contact
Sitemap
Commands out of sync; you can't run this command now
Application for Membership
Part 1 - General Information
Full institution name, including affiliated medical school (if any):
*
Coordinating Investigator Name:
*
Coordinating Investigator Email Address:
*
Other institutional investigators and their e-mail addresses:
Investigator Name 1:
Investigator Email Address 1:
Investigator Name 2:
Investigator Email Address 2:
More institutional investigators?
Yes
No
Investigator Name 3:
Investigator Email Address 3:
Investigator Name 4:
Investigator Email Address 4:
Investigator Name 5:
Investigator Email Address 5:
Investigator Name 6:
Investigator Email Address 6:
Part 2 – Please complete the following regarding criteria for full membership.
Our institution has a dedicated clinic for scleroderma.
Yes
No
Full Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepa
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Our clinic has participated in at least one clinical trial of direct relevance to scleroderma.
*
Yes
No
Please list the clinical trial(s) (Including sponsor) in which you/your institution has participated
Our clinic has participated in a previous clinical trial for a non-scleroderma immunologic or rheumatological disease.
Yes
No
Our clinic has available support personnel experienced in clinical trials and “good clinical practices”.
Yes
No
Our clinic has the ability to recruit patients with scleroderma for clinical trials.
*
Yes
No
Our institution has published at least one manuscript within the last five years describing clinic aspects of scleroderma.
*
Yes
No
Please list the manuscript information:
Should your institution wish to have the initial ($250 USD) and annual ($200 USD) dues waived please express that here, and why. The waiving of dues is considered on a case by case basis and will be reviewed on a yearly basis.
Recaptcha Word Verification:
Submit
Reset
Home
About
Bylaws
Executive Committee
Members
Membership Application
Membership Application Form
Newsletter
Rodnan Skin Score Training
Meetings
Publications
Industry
Rountable
Site Infrastructure Database
Working Groups
Calcinosis
Cardiac
Damage & Activity Index
Gastrointestinal
Juvenile Scleroderma
Lung Disease
Renal Crisis
Skin Disease
Vascular
Definitions Of Disease Onset & Organ Involvement
Grants & Awards
Working Group Grants
Betty Z. Benedict Award
Visiting Fellowships
Travel Awards
Support Us
Contact
Sitemap