Investigator Profile

Salutation:

First Name*:

Middle Initial:

Last Name*:

Degree/Qualification:

Please choose medical specialities you are certified in*:

Please specify

Phone*:

Fax:

E-mail Address*:

Overall experience in clinical trials:

years

Experience in clinical trials as a principal investigator:

years

Site Information

Site Name:

Site Type:

Department:

Address 1:

Address 2:

Address 3:

City:

State/Province:

Zip/Postal Code:

Country:

Phone 1:

Phone 2:

Phone 3:

Fax:

Website:

E-mail Address:

Internet Access:

Yes No

Therapeutic Areas of Trial Experience/Interest*:

Please specify

Phase Experience/Interest:

Phase I

Phase II

Phase III

Phase IV

Please enter your Comments or Requests below:

* Mandatory fields

For more information, please contact us:

For North America Clients:

Ginny Payeur
Tel: +1 650 592 91 01
Fax: +1 650 592 91 09
E-mail: Ginny.Payeur@psi-cro.com

For European, Japanese and ROW Clients:

Olga Alfonsova
Tel: +7 812 320 38 20
Fax: +7 812 320 38 50
E-mail: Olga.Alfonsova@psi-cro.com