ClinCard Acknowledgment Form
Subject First Name: ____________________________ Subject Last Name: ___________________________________
Date of Birth: __________________________
Street Address: ____________________________________________________________________________________
City and State: ____________________________________________________________________________________
Zip Code: _____________________
Contact Telephone(s): ______________________________________________
Email Address: ____________________________________________
Would subject like to be notified via cell phone or email when funds are loaded onto Clincard? Yes
Social Security Number: _____________________
Self
LAR
LAR Name (if applicable): _______________________________
ClinCard # ______________________________________________________
Study Name/Number: _____________________________
Subject ID: ______________________________
Visit
Date
Amount of Stipend
Subject’s Signature
Comments
No