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Investigator Registration Form
Investigator First Name:
Investigator Last Name:
Name of Institution:
Country:
Select
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Chile
China
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C?1?te d`Ivory Coast
Croatia
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Denmark
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Dominican Republic
East Timor
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Fiji
Finland
France
Gabon
Gambia
Georgia
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Guinea
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Guyana
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Hungary
Iceland
India
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Iran
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Ireland
Israel
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Japan
Jordan
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North Korea
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Laos
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Libya
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Luxembourg
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Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Address:
Phone Number:
(Please include country code)
Fax :
(Please include country code)
Email :
Type of Hospital :
(e.g. Supespeciality / Muti speciality Hospital (Private /Govt))
Medical Specialisation :
(e.g. generalist please put internal medicine, family practice)
Indicate if you have a sub-specialisation? :
Main therapeutic area of interest in terms of Clinical Trials :
(e.g. Cardiology, Opthalmology)
Patient age groups do you treat :
(e.g.Paediatric, Adult)
Specific areas of interest for clinical trials, in terms of indications / therapeutic areas:
(e.g. Cardiology, Opthalmology)
Studies conducted :
(Indication/Therapeutic Area)
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