Young Investigator Membership 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: *

If you are currently not involved in any GCT clinical or biologic research, please explain your interest in MaGIC and how you feel you can contribute to the group *

Please indicate which of the following areas of germ cell tumor research you are most interested in participating in (you may indicate more than one area). *

Please upload CV *

Drop your file here or click here to upload

Please upload a Letter of Support from your Program Director or Department Head *

Drop your file here or click here to upload

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