APPLICATION FOR MEMBERSHIP
APPLICATION PROCEDURES
1. Read the Cancer Center Objectives and Membership Guidelines.
2. Select a Program affiliation that best suits your interests from the list included with the Objectives and
Guidelines. We encourage you to discuss your interests with the appropriate Program Leaders in order
to learn about the scientific focus of the Program; its activities; and to provide information to the
Leaders about your scientific interests and potential role in the Program.
3. Complete and submit the Membership Application Form (attached) with the Cancer Relevance
Information Form and Statement, and a complete CV including information pertaining to your current
and pending research support (if applicable).
4. E-mail your completed application in WORD Format to Suzanne Heasley:
Suzanne.Heasley@ucdenver.edu
Revised 01/16/2013
INTERNAL USE ONLY: Application Date:
Application Received:
Membership # Assigned
University of Colorado Cancer Center
Application for Membership
Applicant Name (Last, first, middle, suffix):
Degrees
,
,
,
CU Employee ID (if applicable):
eRA Commons login name:
Primary Affiliate Institution (check one):
UCD Anschutz Medical Campus
CU Boulder
Colorado State University
UCD Downtown Campus
Children’s Hospital Colorado
National Jewish Health
Kaiser Permanente Colorado
Denver VA Medical Center
Denver Health
Other:
School: :
Department:
Division:
Academic position (or equivalent):
Email Address:
CU Campus Box (if applicable):
Work Address:
Work phone:
City:
Work fax:
State:
Pager:
Zip:
Cell:
Please identify any professional, cancer-related organizations in which you hold membership (e.g. ASCO,
AACR, IASLC, ONS etc.):
,
,
,
I am interested in joining the following Program and have discussed my interest with the program
leader (please mark one):
Cancer Cell Biology
Hormone Related Malignancies
Cancer Prevention & Control
Lung, Head & Neck Cancers
Developmental Therapeutics
Molecular Oncology
I specialize in the study and/or treatment of the following areas: (choose up to 3)
AIDS Oncology
Head & Neck Cancer
Radiation Oncology
Bladder Cancer
Hematology/BMT
Renal / Kidney Cancer
Breast Cancer
Hereditary Cancer
Sarcomas
Developmental Therapeutics
Melanoma
Skin Cancer
Endocrine Neoplasms
Neurological Oncology
Survivorship
GI Cancer
Pediatric Oncology
Thoracic Oncology
GYN Oncology
Prostate Cancer
Unspecified
I have reviewed the Cancer Center objectives, requirements and privileges and subscribed to those. I have
attached the following additional word documents to this application:
Statement describing my cancer-related research interests, collaborations, expected use of Shared
Resource facilities, and other contributions to the Cancer Center.
Full, current CV, including information pertaining to my current and pending research support (principal
investigator, award #, sponsoring agency, and dates of support)
Please submit your completed application and the requested attachments in WORD format via email to
Suzanne Heasley at Suzanne.Heasley@ucdenver.edu.
Revised 01/16/2013
CANCER RELEVANCE INFORMATION
A. Please respond to each of the following questions:
1. Help us understand the amount of your research that is focused on cancer-specific activities:
<25% of my time
26 – 50% of my time
51-75% of my time
76-100% of my time
2. How long have you been involved in cancer-related research?
3. List your publications in the last five years that demonstrate a strong cancer focus.
4. List all peer-reviewed grant awards that have supported your research in the last five years (award number,
project dates, sponsor, project title), and identify your specific role (PI, co-investigator, etc)
5. List the investigator initiated clinical trials in which you have been involved in the last five years and identify
your specific role (PI, co-investigator, etc).
6. How will you benefit from membership in the cancer center?
7. Which Shared Resources do you anticipate to use for your research?
8. Please provide any additional information you may find relevant to demonstrate your commitment to
cancer-research.
Revised 01/16/2013
B. Statement of Cancer -Related Activities – In the following space, please describe your cancerrelated activities the committee should take into consideration when evaluating you for membership.
Researchers: Please summarize in lay terms the primary focus of your research and the cancerrelevance of that research. Other Non-research Applicants: Please describe your cancer-focused
activities.
Revised 01/16/2013