Gates Institute Membership Application

Name*

First Name

Last Name

Degree(s)*

PhD MD MD, PhD

Other:

Position*

Professor Assistant Professor Associate Professor Instructor Director Endowed Chair

Other:

Please include name of endowed chair, if applicable.*

Institution Affiliation*

University of Colorado Anschutz Medical Campus University of Colorado Boulder National Jewish Health Colorado State University Colorado School of Mines

Other:

Primary Appointment*

Secondary Appointment

Email Address*

Office or Lab Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Office or Lab Phone Number*

Mobile Number*

Profile Web page

Please provide a URL link to your profile or lab's webpage

Area of Research Focus*

Cardiology Ehlers-Danlos Syndrome (ED) Epidermolysis Bullosa (EB) iPSC's Oncology Orthopedics Ophthalmology Wound Care

Other:

Please select one or more areas of focus.

Research Interest

Please provide a brief summary (200 words or less) of your research interest relevant to the Gates Institute for our website.

Core Facilities *

Gates Biomanufacturing Facility Histology (Morphology and Phenotyping) Flow Cytometry Organoid Core Stem Cell Biobank and Disease Modeling Genomics Human Immune Monitoring

Please check all of the core facilities that you would be interested in utilizing.

Each year we host outstanding undergraduates for the Gates Summer Internship Program (GSIP) and assign interns to various members' labs. Would you be interested in serving as a mentor for one of our qualified applicants? *

Yes No

Please note that your response does not automatically enroll you as a GSIP mentor.

Biosketch*

No File Chosen

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Please provide a copy of your current biosketch.