APPLICATION FOR

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					                          APPLICATION FOR
             LISTING OF RESEARCH STUDIES ON SMFM.ORG

Please e-mail this application along with the study to be posted and any
related materials (attachments) to Julie Miller at jmiller@smfm.org
APPPLICANT’S NAME: _______________________________________________________
Must be a member of the Society of Maternal-Fetal Medicine


DESIRED POSTING DATE: ____________________________________________________
Application must be submitted at least 45 days in advance


STUDY TITLE:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


INSTITUTION(S):_____________________________________________________________
______________________________________________________________________________


SPONSOR:___________________________________________________________________
_____________________________________________________________________________


CONTACT INFORMATION: Name, address, phone, fax, e-mail address, URL as applicable.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


REQUIREMENTS:
   1. An institutional IRB approval letter must be submitted
   2. At least one of the investigators must be a regular member of the SMFM
   3. The research should generally be related to pregnancy or Perinatal outcome
   4. There is a fee of $50 for the initial listing. The minimal listing period is 6 months.
       The fee is to be submitted with the application. Please complete the payment
       information at the end of this document.
   5. Investigators who wish to extend their listing beyond the previous period should
       contact the SMFM. Otherwise, studies are removed from the site when the study
       listings are updated semiannually.
   6. The investigators, institutions and sponsors acknowledge that:
          a. Listing on the Society of Maternal-Fetal Medicine website is NOT an
              endorsement or proclamation of approval.
          b. Listing of research studies is offered as a service to individual society
              members. The Society of Maternal-Fetal Medicine is NOT participating in
              the conduct or monitoring of the studies listed.


____________________________________________________                     _________________
              Investigator/Member signature                                     Date
Please make check payable to:
       Society for Maternal-Fetal Medicine
Remit to:
       Society for Maternal-Fetal Medicine
       409 12th Street, SW
       Washington, DC 20024

Credit Card Payment:
[ ] Visa                [ ] MasterCard      [ ] American Express

Account #: __/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__

Expiration Date: ______________

Name of Cardholder: ____________________________________

                                     FOR OFFICE USE
                 ACTION                                             DATE
           Application received
            IRB proof received
     Payment- check credit card other
         Submitted to Webmaster
               Posted to site


SMFM.ORG STUDY LISTING APPLICATION                                                   2/2

				
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posted:2/12/2013
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