Member Application

First name *

Degree(s) (Please list all) *

Department *

Last name *

Title (Official academic title) *

Institution (With whom you are employed) *

Institution address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Email address *

Office phone *

Cell phone *

If applicable, please list any GCT-related clinical trials that you have been or are currently involved in: *

If applicable, please list any GCT-related research projects that you have been or are currently involved in: *

We ask that all MaGIC membership applicants list two references who are current members of MaGIC. Please list the names of the references: *

Please indicate which of the following areas of MaGIC you would be most interested in participating in (you may indicate more than one): *

Please upload CV *

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