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* 1. Name

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* 2. Credentials:

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* 3. Title:

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* 4. Organization/Institution:

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* 5. Phone Number:

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* 6. Email Address:

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* 7. LinkedIn Profile:

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* 8. What year did you join SOCRA?

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* 9. Enter your bio below (maximum 250 words):

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* 10. List your participation in SOCRA Activities (e.g. speaker at conference, chapter leadership, etc.):

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* 11. Enter your Vision Statement below (maximum 250 words):

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* 12. Which of the following best describes your primary employment setting?

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* 13. Please selected your primary therapeutic area:

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* 14. Please list any memberships and/or roles in other organizations which are relevant to clinical research:

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* 15. If you have been endorsed or recommended by someone in SOCRA leadership, please list their names here:

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* 16. Upload your CV:

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* 17. Upload your headshot:

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* 18. Enter your full name below to acknowledge that you:

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