FACULTY MEMBERSHIP APPLICATION Tulane Cancer Center
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1 FACULTY MEMBERSHIP APPLICATION Tulane Cancer Center 1430 Tulane Ave., Box SL-68, New Orleans, LA J. Bennett Johnston Building, Mezzanine (Floor 1A), Suite A102 (504) , fax (504) , or Name: Social Security Number: Academic Rank: Academic Department and Section: Other positions and titles: Office Mailing Address: Campus Mailbox: Office Location (Building & room number): Lab or Clinic Location (Building & room number): Phone: Fax: Pager: Cell: Home Address: Home Phone: Webpage:
2 Major Research Interests: Major Teaching Responsibilities: Major Clinical Responsibilities
3 Please provide a brief PROSE BIOGRAPHICAL NARRATIVE in the space below, or include as an attachment. This will be a brief paragraph in complete sentences, describing matriculation and professional interests, as opposed to an NIH-style bio-sketch in list format. Please list four to ten selections of your most relevant recent cancer-related PUBLICATIONS, or include as an attachment. Please let us know which cancer-related publications you consider most representative of your work.
4 RESEARCH SUPPORT Please indicate status of support, i.e., Active, Pending or Planned. If you need more forms, please copy this page. Name of Research Program: Source and Identifying Number: Principle Investigator: Your role on project: % effort: Dates and costs of entire project: Dates and cost for current year: Specific aims of project: Name of Research Program: Source and Identifying Number: Principle Investigator: Your role on project: % effort: Dates and costs of entire project: Dates and cost for current year: Specific aims of project:
5 SIGNATURES: Applicant: Date: Department Chair: Date: Director, Tulane Cancer Center: Date: ATTACHMENTS: Please attach a current Curriculum Vitae and a photograph, or a digital photograph to mcross@tulane.edu.
6 RESEARCH PROGRAMS: Molecular Genetics & Viral Oncogenesis Cell Signaling Epidemiology, Prevention and Control Immunology Clinical Research & Research Training MEMBERSHIP CATEGORY DEFINITIONS: Program Member: Has highest priority for participating in Center-based applications for grants and contracts and for utilization of the Center's resources. 1 University faculty member with at least one active research program fitting the program objectives of the Center. 2 Principal investigator of at least one research program extramurally funded by agencies recognized by the National Cancer Institute. 3 Active participant in research, education and/or administration of the Center and a leader in promoting its development. Contributing Member: Has priority for participating in Center-based applications for grants and contracts and for utilization of its resources. 1 University faculty member with at least one active research program fitting the program objectives of the Center. 2 Active participant in research, education and/or administration of the Center and a leader in promoting its development. Associate Member: Has access to the resources of the Center as well as the opportunity to participate in Center-based applications for grants and contracts. 1 University faculty member, member of another educational and/or research institution or organization, or an individual who is interested in at least one of the programs of the Center. 2 Regular participant in at least one of the functions of the Center.
7 Clinical faculty members please indicate your areas of specialty. Specialty Please put an X next to your areas of specialty. Please select ALL that apply. Adrenal Gland Tumors Anal Cancer Apheresis Basal Cell Carcinoma Bladder Cancer Bone Marrow Transplant Bone Tumors Brachytherapy Brain/Central Nervous System Tumors Adult Brain/Central Nervous System Tumors Pediatric Breast Cancer Carcinoid Tumors Carotid Body Tumors Cervical Cancer Chemotherapies Clinical Trials Colorectal Cancer Cutaneous Lymphoma Dermatologic Cancers Desmoid Tumors Endocrine Tumors Endometrial Cancer Esophageal Cancer Ewing's Sarcoma Gall Bladder and Bile Duct Tumors Gastric Cancer Gastrointestinal Cancers Genitourinary Cancers Germ Cell Tumors Glioblastoma Gynecologic Cancers Head & Neck Cancers Hematologic Disorders Benign & Premalignant Hematologic Malignancies Hodgkin's Disease Islet Cell Tumors Kaposi's Sarcoma Kidney Cancer Leukemias Adult
8 Leukemias Pediatric Liver Cancer Lung Cancer Lymphomas Mammography Melanoma Meningioma Merkel Cell Tumors Mesothelioma Moh's Micrographic Surgery Multiple Myeloma Nasal Cavity Cancer Neuroblastoma Neuroendocrine Tumors Neuro Oncology Neurosurgery Ophthalmic Tumors Oral Cavity Cancer Ovarian Cancer Pancreatic Cancer Pain Management Paranasal Sinus Cancer Pediatric Cancers Prostate Cancer Psychoncology Radiation Oncology Rectal Cancer Renal Cancer Retinoblastoma Rhabdomyosarcoma Salivary Gland Tumors Sarcomas Adult Sarcomas Pediatric Sentinel Node Mapping Sinus Cancers Skin Cancers Spinal Cord Tumors Squamous Cell Carcinoma Stem Cell Transplant Stereotactic Radiosurgery Surgical Oncology Testicular Cancer
9 Thymoma Thyroid Tumors Urologic Cancers Wilms' Tumors
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