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									The Ohio State University
Comprehensive Cancer Center (OSUCCC)

                                     MEMBERSHIP APPLICATION

1. NAME (include degree(s):

2. ACADEMIC TITLE:

3. DATE OF BIRTH*:

       Note: This information is used by the OSUCCC Grants and Award Committees for reviewing members
       against sponsor criteria for funding or prestigious award opportunities. This information will be kept
       confidential.

4. MAILING ADDRESS:



5. OFFICE PHONE NUMBER:                   (614)

6. FAX NUMBER:                            (614)

7. E-MAIL ADDRESS:

8. COLLEGE:

9. DEPARTMENT (TIU):

10. DIVISION (if applicable):

11. Please provide a brief summary (less than 100 words) describing your cancer-
   relevant research interests:




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                                                                                                                Rev. 10/03
12. Indicate which of the seven OSUCCC Research Programs you believe is most aligned
    with your research interests:
                                                   Primary      Secondary
    Cancer Control
    Experimental Therapeutics
    Immunology
    Molecular Biology and Cancer Genetics
    Molecular Carcinogenesis and Chemoprevention
    Viral Oncogenesis

13. Check the OSUCCC Shared Resources/Services you would anticipate using:

           Analytical Cytometry
           Behavioral Measurement
           Biomedical Informatics
           Biorepository and Biospecimen
           Biostatistics
           Clinical Trials Office
           Clinical Treatment Unit/Clinical Trials Processing Unit
           Comparative Pathology and Mouse Phenotyping
           Leukemia Tissue Bank
           Microarray
           Microscopy
           Nucleic Acid
           Pharmacoanalytical
           Proteomics
           Small Animal Imaging




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14. Please provide a listing of all ACTIVE research funding (include grant title,
   sponsor, grant number, total amount and project period):




15. GENERAL RECRUITMENT INFORMATION (Newly recruited faculty):

   A. What date did you join the faculty of OSU?

   B. If appropriate, where is your current or proposed laboratory space located?

            Building     Room number           NSF (net square feet)
       a.
       b.
       c.

   C. Briefly describe the components of your recruitment package?

      Research personnel support
      Equipment
      Other start-up




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        Please attach a copy of your CV to this application and return by
        email to Mary Beth Beguin at marybeth@osu.edu


                                     Mary Beth Beguin
                              OSU Comprehensive Cancer Center
                                    650 Ackerman Road
                                      Columbus, OH
                                       614-293-5153




 FOR OSUCCC OFFICE USE ONLY:

 Membership Category:        FULL     ASSOCIATE         INTRODUCTORY        STAFF



APPROVALS:


OSUCCC Program Leader(s)                                   Date



OSUCCC Program Leader(s)                                   Date



Michael A. Caligiuri, M.D.                                 Date
Director, OSUCCC




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