Membership Application

If you haven't already done so, please review the benefits of IMACS membership

Demographics

Applicant Information

^* Indicates Required Fields Optional information is used to facilitate use of information on IMACS members.
First Name^*:
Last Name^*:
Degree(s) (PhD, MD, ... )^*:
Medical Specialty or Profession^*:
Email^*:
Membership Type^*
Associate	Associate Members have access to IMACS tools. Associate Members must reapply for membership after one year.
Full	Full Members have access to IMACS tools and may participate in studies. Full Members do not need to reapply.

Affiliation Information

Affiliation (check all that apply):
Hospital	Private Clinic
University	Government
Non-profit	Industry
Other, please specify:

Primary Affiliation Address

Affiliation Name^*:
Street Address (line 1)^*:
Street Address (line 2):
City^*:
Country^*:
State/Province^*:
State/Province^*:	If not from North America, please enter your state (if any):
Zip/Mail Code^*:
Telephone^*:
Fax:
Web Address:

Please complete the optional information below to facilitate communication among IMACS members.

Optional Information

Myositis Research

Are you interested in myositis research?
Yes No

If yes, what areas of myositis research interest you? Select all that apply:
Epidemiology	Diagnostic/Classification/Subclassification Criteria
Clinical presentation and manifestations	Natural history of disease
Disease assessment	Outcomes research
Therapy / prognosis	Clinical trials
Muscle structure or ultrastructure	Muscle molecular biology, biochemistry or function
Genetic risk factors	Environmental factors / myotoxins
Animal models	Pathology
Immunology	Pathogenesis of disease
Pre-clinical therapeutic development
Other, please specify:

Myositis Patients

Are you responsible for the clinical area of myositis patients?

Yes
No

If yes, What types of myositis patients are under your care?

Adult
Juvenile
Both

Please select all clinical forms of myositis that you care for from the following:

Dermatomyositis
Polymyositis
Inclusion body myositis
Other, please specify:

Curriculum Vitae

Please have your CV updated before you begin the membership application. Your CV is requested for membership approval as a FULL member of IMACS (not for Associate Members). Please attach your CV in one of the following file formats:

Adobe PDF document (filename.pdf)
Word document (filename.doc)
Rich Text Format (filename.rtf)

CV:

National Institute of Environmental Health Sciences

Demographics

Myositis Research

Myositis Patients

Curriculum Vitae

National Institute of Environmental Health Sciences