MUSC Membership Program Application This application is for Hollings Cancer Center's (HCC) Membership Program for MUSC faculty members who have an interest in cancer or are involved in cancer-related research. >> For questions about this form, please contact Carla Frichtel, Assistant Director of Research Development, 843-792-5489 or firstname.lastname@example.org. >> Please read the Hollings Cancer Center Membership Guidelines (PDF) before completing this application. Membership Category Research Clinical Member Affiliate Member Please complete the following: Name of Applicant* (Please include first and last names) Email Address* University Academic Title* University Department* Mailing Address 1* Mailing Address 2 City* State* -Select One-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AfricaArmed Forces Americas (except Canada)Armed Forces CanadaArmed Forces EuropeArmed Forces Middle EastArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code* Office Phone Number* (Please include area code) Fax Number* (Please include area code) Please read the Hollings Cancer Center Membership Guidelines before completing this application. Click on the box for the membership category for which you are applying: Research Programs Lipid Signaling in Cancer Cancer Genes & Molecular Regulation Developmental Cancer Therapeutics Cancer Immunology Cancer Control (Clinical Member and Affiliate Member applicants; Research and Research Associate member applicants who want to be included in clinical meetings and activities may also check here:) Clinical Programs Bone Marrow Transplant/Malignant Hematology Breast Cancer Cutaneous Oncology Gastrointestinal Tumor Genitourinary Cancer Gynecologic Oncology Head & Neck Cancer Neuro-Oncology Thoracic Oncology For Research applicants, please provide a brief statement regarding your primary cancer related research interests and activities: 1600 characters maximum For Clinical and Affiliate applicants, please describe your cancer-related interests (clinical education, outreach, etc.) 1600 characters maximum All applicants must include current NIH Biosketch - Include CV if Biosketch not available* (Please attach .pdf or .doc file with NO SPACES in the filename) Fields marked with * are required.