Please indicate the type of application you wish to submit.
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New membership Membership renewal
First name:
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Last name:
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Other names under which you have published, if applicable:
UChicago ID number:Who Am I search page.)
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Please indicate the type of membership for which you are applying.
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Full Associate Trainee Associate
Information on membership categories can be found in this document.
Degree(s) attained:
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Please specify "Other":
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Current title:
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Named Professor Professor Associate Professor Assistant Professor Instructor Other
Please specify your named professorship:
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Current trainee status:
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PhD Student Postdoctoral Fellow/Scholar Clinical Fellow Medical Student Other
Please specify "Other."
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Department or program:
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Anesthesia & Critical Care Argonne National Labs Ben May Department Biochemistry/Molecular Biology Committee on Cancer Biology Committee on Clinical Pharmacology & Pharmacogenomics Committee on Development, Regeneration & Stem Cell Biology Committee on Genetics, Genomics & Systems Biology Committee on Immunology Committee on Medical Physics Committee on Microbiology Committee on Molecular Metabolism & Nutrition Human Genetics Medicine Microbiology Mol Gen/Cell Bio Obstetrics & Gynecology Pathology Pediatrics Physical Sciences Division Psychiatry & Behav. Neurosci Public Health Sciences Radiology Radiation & Cellular Oncology School of Molecular Engineering Social Sciences Division Surgery Other
Start date of current training (MM-YYYY):
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Expected completion date of current training (MM-YYYY):
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Please upload your current curriculum vitae (optional for Trainee Associate Member applicants).
PDF file only
Have you identified a faculty research mentor?
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Yes
No
Mentor first name:
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Mentor last name:
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Mentor email:
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Mentor phone:
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Mentor UCCCC program affiliation:
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Molecular Mechanisms of Cancer Immunology and Cancer Clinical and Experimental Therapeutics Cancer Prevention and Control Not a UCCCC member Unsure
Please indicate which UCCCC research program is most closely aligned with your interests and the cancer-relevant focus of your research.
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Molecular Mechanisms of Cancer Immunology and Cancer Clinical and Experimental Therapeutics Cancer Prevention and Control Non-Aligned Unsure
Please provide a brief summary of your research focus, including its relevance to cancer (500 words or less).
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Please describe any interdisciplinary or collaborative cancer-related research with other members of the UCCCC (500 words or less).
If applicable, please provide the title of any clinical trial for which you are currently the PI.
Clinical Trial 1: IRB# (if applicable)
Clinical Trial 1: NCT# (if applicable)
Do you have another clinical trial to add?
Yes
No
Do you have another clinical trial to add?
Yes
No
Do you have another clinical trial to add?
Yes
No
Do you have another clinical trial to add?
Yes
No
Do you have another clinical trial to add?
Yes
No
Please list the title, IRB# and NCT# for all additional clinical trials for which you are the PI.
Please specify "Other/New."
Please indicate the source of any cancer-related funding you have secured within the past 3 years. Mark all that apply.
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Grant type (mark all that apply):
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K08 funding institute (e.g., NCI):
K08 funding (annual direct costs):
K12 funding institute (e.g., NCI):
K12 funding (annual direct costs):
K22 funding institute (e.g., NCI):
K22 funding (annual direct costs):
K23 funding institute (e.g., NCI):
K23 funding (annual direct costs):
R00 funding institute (e.g., NCI):
R00 funding (annual direct costs):
R01 funding institute (e.g., NCI):
R01 funding (annual direct costs):
Do you have another R01 to add?
Yes
No
R01 funding (annual direct costs):
Do you have another R01 to add?
Yes
No
R01 funding (annual direct costs):
U01 funding institute (e.g., NCI):
U01 funding (annual direct costs):
NIH institute (e.g., NCI):
NIH funding (annual direct costs):
NCI award title:
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NCI award number:
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NCI award funding (annual direct costs):
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NSF award title:
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NSF award number:
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NSF award funding (annual direct costs):
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Funding organization:
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Award title, if applicable:
Award number, if applicable:
Award funding (annual direct costs):
Please indicate the source of any cancer-related funding that is pending. Mark all that apply.
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Pending grant type (mark all that apply):
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Pending K08 funding institute:
Pending K08 grant number:
Pending K08 funding (annual direct costs):
Pending K12 funding institute (e.g., NCI):
Pending K12 grant number:
Pending K12 funding (annual direct costs):
Pending K22 funding institute (e.g., NCI):
Pending K22 grant number:
Pending K22 funding (annual direct costs):
Pending K23 funding institute:
Pending K23 grant number:
Pending K23 funding (annual direct costs):
Pending R00 funding institute (e.g., NCI):
Pending R00 grant number:
Pending R00 funding (annual direct costs):
Pending R01 funding institute (e.g., NCI):
Pending R01 grant number:
Pending R01 funding (annual direct costs):
Do you have another pending R01 to add?
Yes
No
Pending R01 funding institute:
Pending R01 grant number:
Pending R01 funding (annual direct costs):
Do you have another pending R01 to add?
Yes
No
Pending R01 funding institute:
Pending R01 grant number:
Pending R01 funding (annual direct costs):
Pending U01 funding institute (e.g., NCI):
Pending U01 grant number:
Pending U01 funding (annual direct costs):
NIH institute (e.g., NCI):
Pending NIH grant number:
Pending NIH funding (annual direct costs):
Pending NCI award number:
Pending NCI funding (annual direct costs):
Pending NSF award number:
Pending NSF funding (annual direct costs):
Pending award title, if applicable:
Pending award number, if applicable:
Pending funding (annual direct costs):
Please use this space for any additional information you would like to share about your cancer-related research funding, including the funding organization, award title, award number and annual direct costs for any current or pending funding sources that were not accommodated by the fields provided.
Please indicate the nature of your training support (check all that apply).
T32 funding institute (e.g., NCI):
F31 funding institute (e.g., NCI):
F32 funding institute (e.g., NCI):
K99 funding institute (e.g., NCI):
Award name, if applicable:
Award number, if applicable:
Work email:
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Personal email:
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Work phone:
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Work street address (line 1):
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Work street address (line 2):
City:
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State/province:
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Country:
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Zipcode:
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Name of administrative assistant, if applicable:
Please share any additional information you feel is relevant to your qualifications for UCCCC membership.
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No
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