New Site Application

Section 1:  Representation Agreement and Payment Terms






By electronically signing this document, Institution Agrees to the above Terms and Conditions:


Section 2: Site and PI Information

Institution Legal/Billing Location

The Legal Name/Address is the main address of the Institution who employs or contracts the study staff and where payments are received, etc.  The company name must be searchable in your state's Business Entities Database  (Ex: Florida = http://search.sunbiz.org)



The Legal Name/Address must be searchable on your state's 
Business Entities Record Database. 
(Example: Florida - http://search.sunbiz.org/Inquiry/CorporationSearch/ByName/ 


IMPORTANT: If your Legal address is different than the Facility address (where the study will take place) only enter your Legal address here.  The Facility address will be added in a later section.
 







Facility Location
The Facility Site Name/Address MUST be where the study takes place. 

This may be different than the Legal Name/Address. If so, then please
 enter the name and address of that Facility, Private Practice, or Research Center here as Site Name/Address.

This Name/Address must be searchable on your state's
Business Entities Database. 
(Example: Florida - http://search.sunbiz.org/
 







Site Contact Information






Site Experience Information



Please provide details for the site's 3 most recently completed studies:



Investigator Information

Please submit the below information for each Investigator in your network.

If you have more than one, please click on the Add Another Investigator button on the bottom right of this page to create additional Investigator submissions.











If you have more than one Investigator, please click on the Add Another Investigator link above.