Cardiovascular Center Membership Enrollment

Please complete this form in its entirety. All information requested is important for both processing your enrollment and including you in important aspects of the Cardiovascular Center’s activities.

First Name:
Middle Initial:
Last Name:
Degrees Held:
Title:
Primary Department:
Do you have a Joint Appointment?:  Yes   No
If yes, please indicate with which department:
School/College/Unit:
Office Address:
Box:
Phone:
Fax:
Email:
UM Employee ID Number:
Description of current primary role(s) in cardiovascular field:

(Use CTRL CLICK to check all that are applicable; use CTRL CLICK on highlighted selections to deselect)
If “Other” selected, please specify:
Upload your curriculum vitae:
Cut and paste most recent curriculum vitae here:
Faculty/Staff Profile Hyperlink:
(in http://www...format)
Describe briefly your current cardiovascular work (e.g., ongoing research, clinical role, education, policy/advocacy, administration) and include collaborations with other CVC researchers, educators, and/or clinicians:
Research Focus Areas:

(Use CTRL CLICK to check all that are applicable; use CTRL CLICK on highlighted selections to deselect)
If “Other” selected, please specify:
Collaborative Team Areas:
CVC is divided into teams which meet regularly. CVC members can be associated with more than one Collaborative Team. Please indicate which team(s) is of most interest to you.

(Use CTRL CLICK to check all that are applicable; use CTRL CLICK on highlighted selections to deselect)
Please elaborate on how you plan to contribute specifically to the Cardiovascular Center: