Pre-Qualification Questionnaire Clinical Investigators Consortium P.O. Box 9218 Lombard, Illinois 60148, USA www.CICdomain.com Contact: A.K. Hazari Phone: 630.916.1886 Email: [email protected] Acute Myelogenous Leukemia Trial (6663) Upon Submission The Sponsor/CRO Will Contact Your Site Directly DO NOT CONVERT TO PDF. EMAIL IN WORD FORMAT ONLY. Site Name Email Address Phone Number Fax Number Street Address City State Zip Code Country Investigator Name License Number State License Issued PI Specialty Board Certification PI Sub-Specialty Board Certification Trials Experience # of Trials Completed Yes No Yes No Years A Phase 3 Study of Active Immunotherapy With Study Drug vs Placebo as Maintenance Therapy in Patients >60 Years of Age With Newly Diagnosed AML in Complete Remission Following Physician’s Choice Induction Plus or Minus Consolidation Therapy.