ReSolution Latin America

* All questions contained in this form are strictly confidential and for internal ReSolution use only.

Name (Last, First):

Title (e.g.- Dr, Mr., Ms. etc.):

Degree (Tick all that apply): M.D. Ph.D MBA Pharm. D. R.N. Other (please specify):

Institution/Hospital:

Type of Institution: Private Public

Practicing Physician: Yes No

Address 1:

Address 2:

City:

Zip Code:

Country:

Telephone:

Email:

Fax:

Cell Phone:

THERAPEUTIC SPECIALIZATION
Therapeutic Area(s): (e.g. - oncology, infectious disease):
Sub-specialization (e.g. – pancreatic cancer, HIV):	1.	2.
	3.	Other (please specify):
Comments (please feel free to include any relevant comments):

CLINICAL TRIAL EXPERIENCE
Previous Clinical Trial Experience:
Phase:	Number of Trials:
Phase I:	Phase II:
Phase III:	Phase IV:
Comments (please feel free to include any relevant comments):

I hereby agree that ReSolution may keep my details on file and contact me with possible relevant opportunities.
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