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Neuroscience Research Center Member Application

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Please complete the survey below to apply for membership with the Neuroscience Research Center (NRC).

All fields are required, unless otherwise stated.

You are able to save your responses and return at a later time if needed.

Please contact Erik VanNewenhizen (evannewenhizen@mcw.edu) if you have any questions or concerns regarding this survey.

Thank you!

First Name

* must provide value

Last Name

* must provide value

Credentials

Do you have a faculty appointment at MCW?

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Yes

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Appointment Type

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Professor

Associate Professor

Assistant Professor

Instructor

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Please select one of the following:

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MCW Staff

MCW Post-Doc

MCW Student

Other

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Please provide your organization and title

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Department

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Division

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Do you have a VA appointment?

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Yes

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Best Contact Phone

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Primary Work Address

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Building / Room Number

First Name

Last Name

Phone

First Name

Last Name

Phone

Attachment:Membership types.pdf

What level of Membership are you requesting?

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Primary

Affiliate

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Please upload your CV

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Upload file

Choose area(s) of research (check all that apply)

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Addiction

Human Behavioral Research

Muscular Dystrophies

Neurodegenerative Disorders

Neuroinflammation

Neuro-oncology

Opthalmology & Vision Research

Pain

Psychiatric Disorders

Spinal Cord Injury & Repair

Traumatic Brain Injury

Other

If "Other", please enter your area(s) of research.

What type of research do you work in? (check all that apply)

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Human

Animal

Computational

Cellular/Molecular

Biochemical

Medical Chemistry

N/A

By signing below and clicking 'submit', you are agreeing to the NRC Membership Criteria and Expectations.

Attachment:Member Expectations.pdf

Signature

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Add signature

Date

M-D-Y

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.