MASSEY CANCER CENTER
APPLICATION FOR MEMBERSHIP
Instructions
To apply for membership in the Massey Cancer Center, please complete the attached
application form. Applications must be approved and signed by the applicant’s Department
Chair (see page 3 of application) before forwarding for review. After the form is completed
and signed, please forward the application with the required attachment by mail to the
address listed below:
Julie C. Schaum, MS
Research Center Grants Manager
Massey Cancer Center
P.O. Box 980037
Richmond, VA 23298-0037
E-mail: jschaum@mcvh-vcu.edu
(For questions, call (804) 628-3614)
Required attachment:
1) Recent curriculum vitae including bibliography
All applications are reviewed by the Cancer Center’s Senior Leadership at its regularly
scheduled monthly meetings. Applicants will be notified of their approval status following
the meeting.
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For office use
Membership type: ______________
Program(s): ___________________
Massey Cancer Center
APPLICATION FOR MEMBERSHIP
Name:
Date:
Faculty Appointment:
Department:
Office Phone:
Fax:
E-mail:
1. Cancer research area(s) of interest:
__ Biochemistry and Biophysics
__ Endocrinology
__ Biostatistics
__ Epidemiology
__ Carcinogenesis
__ Immunology
__ Cellular Biology and Genetics
__ Molecular Biology and Genetics
__ Chemistry
__ Risk and Prevention
__ Clinical Investigations
__ Virology
__ Education/Outreach
__ Preclinical Pharmacology and Experimental Molecular Therapeutics
__ Other (please specify): _____________________________________________________________
2. Primary research interests and experience (please describe briefly):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3. Number of students in training supervised by applicant:
Residents/
Fellows
_____
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Masters
Level
_____
Ph.D.
Candidate
_____
Post
Doctoral (Ph.D.)
_____
4. Cancer- related research projects in which the applicant participates:
Principal Investigator
Funding Organization
Grant/Contract Number
Project Period
Title
Direct Costs
Total Costs
Principal Investigator
Funding Organization
Grant/Contract Number
Project Period
Title
Direct Costs
Total Costs
Principal Investigator
Funding Organization
Grant/Contract Number
Project Period
Title
Direct Costs
Total Costs
5. Participation in cancer- related committees/ organizations:
Committee Name
Parent Organization
Applicant’s Role
I have read the membership policies of the Massey Cancer Center and agree with the
objectives and requirements stated therein.
_________________________________
Applicant Signature and Date
APPROVED BY:
__________________________________
Department Chair Signature and Date
Required Enclosures: Curriculum Vitae
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