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First Name:*

Middle Name:

Last Name:*

Degree(s):

Institution/Employer:*

Primary Trial Site:*

Address 1:*

Address 2:

City:*

State:

Zip/Postal Code:*

Country:*

Phone:*

Fax:

Email:*

Address Type:*

HomeOffice

Clinical Trial Manager/Administrator Information
Use address information from above?

Name of Manager/Administrator:*

Address of Manager/Administrator:*

Address 2 of Manager/Administrator:

City of Manager/Administrator:*

State of Manager/Administrator:

Zip Code of Manager/Administrator:*

Country of Manager/Administrator:*

Phone of Manager/Administrator:

Email of Manager/Administrator:

*Do you have previous clinical trial experience? Yes No

*Did you enroll at least one patient in a clinical trial in the last 12 months? Yes No

Practice Sub-Specialization (Check one or more)*

Interest (Check one or more)*

Bladder Cancer
Kidney Cancer
Penile Cancer
Prostate Cancer
Testicular Cancer
All/General

Adult
Pediatric
Both

Practice Type (Check one only)*
Fulltime Academics
Academics and Private Practice Blend

Fulltime Private Practice
# of Urologists in Practice:

Industry Employment (Check only one) *

I am not employed by a pharmaceutical company.
I am employed by a pharmaceutical company. Please explain:

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SUO Clinical Trials Consortium Membership