ACTRI Membership Application

ACTRI Membership Application
Please Answer the Following Questions
Approved Membership Criteria
General Membership (Highest Level) = Answer YES to any one of the questions 1, 2, or 3. The status is Approved - General

Associate Membership = If all questions are No for 1, 2, and 3 but answer YES to any one of questions 4, 5 or 6 = Associate Membership

Affiliate Membership = If answers 1, 2, 3, 4, 5, and 6 all = NO, then Question 7. must select any option except for None. 

1. Have you or do you currently serve as a PI or co-PI at UC San Diego or affiliated institutions on funded research? *

YES NO
2. Do you have a track record of clinical and/or translational research at UC San Diego or an affiliated institution? *

YES NO
3. Are you enrolled in a KL2, K12, K08 or K23 program at UC San Diego or affiliated institutions? *

YES NO
4. Do you currently participate in the ACTRI CREST, or Translational Science Certificate programs? *

YES NO
5. Do you currently participate in ACTRI activities (e.g., reviewing pilot project grants)? *

YES NO
6. Have you or do you currently collaborate in research conducted by other ACTRI General Members? *

YES NO
7. ACTRI Partner Institution or Organization *

University of California, San Diego Burnham Institute J Craig Venter Institute La Jolla Institute for Allergy & Immunology Palomar Pomerado Health Salk Institute San Diego State University None
Personal and Contact Information

* Indicates Required Fields
Are you a UCSD PI or Co-PI? *

YES NO
Biosketch/CV Upload

Upload a File
Note: Biosketch files MUST be in PDF, Microsoft Word (.doc), or Word 2007 (.docx) format. Cancel of
Applicant *

First Name Middle Initial Last Name
Applicant's Academics *

(PhD, MD, etc.) Department Division
Phone Number *

Area Code Phone Number
Applicant E-mail Address *
Should be Empty:

ACTRI Membership Application

Please Answer the Following Questions