Clinical Trials (EPI 205)

Clinical Trials (EPI 205)

Winter 2016

First Name: / Last Name: / Middle Initial:
Degree(s): Choose a response / Other:
Daytime phone number (include area code if in U.S.):
Email address:
Date of Birth: / Month: Choose a month / Day: Choose a day / Year: / Sex:
Are you Hispanic (or Latino): ☐ Yes ☐ No
Race (Mark all that apply) / ☐American Indian/Alaska Native / ☐Asian / ☐Black or African American
☐Native Hawaiian or Other Pacific Islander / ☐White

What is your student status in the UCSF Graduate Division: Choose a response
If enrolled in UCSF Graduate Division, what is the name of your Graduate Program:

Other than student status in the UCSF Graduate Division, do you have another position/affiliation at UCSF?
☐ Yes ☐ No
If yes, complete below  / Do you have a position/affiliation with another institution?
☐ Yes ☐ No
If yes, name of institution:
If yes, complete below 
Position / Choose a response / Choose a response /
School / Choose a response / Choose a response /
Department / Choose a response / Choose a response /
Division / Choose a response / Choose a response /
Payment Fee*: Check one
☐ $1134.00 (for UC affiliated personnel) / ☐ $1701.00 (for non-UC affiliated personnel)
Payment Options:
☐ Enclosed is a check payable to “UC Regents”
☐ Bank wire transfer (contact Patty Tan, , for details)
☐ Will provide credit card information (please complete attached page)
☐ My Department is sponsoring me to attend the course. Complete the information below:
Business Unit # (5)SFCMP / Account ID# (5) 57825 / Fund ID# (4) / Dept ID# (6)
Project ID# (7) / Activity Period (2) / Function ID# (2) / Speedtype # (10)
Authorizing signature: / / (You may insert .jpg of electronic signature)
Name of person authorizing recharge:
Contact email:
Return to Olivia De Leon by December 14, 2015: UCSF Campus Mail Box 0560 OR Training in Clinical Research Program, UCSF Dept. of Epidemiology and Biostatistics, 550 16th Street, 2nd Floor, San Francisco, CA 94143.
Fax: (415) 514-8150 Phone: (415) 514-8231 Email:

*The TICR Program will provide a refund (minus $75 withdrawal fee) only if students request this within 24 hours of the 2nd lecture in the course.

CREDIT CARD AUTHORIZATION FORM

PLEASE ENTER YOUR CREDIT CARD INFORMATION

OR if you prefer, contact Patty Tan by e-mail to provide information by phone or secure e-mail

Name on card:
Card Billing Address:
City:
State:
Zip:
Card Type: / Visa:☐MasterCard: ☐
Card Number: / Will call with credit card number:☐
Expiration Date (MM/YY): / /
Security Code # (On back of card)
Amount to be charged: / $
Today’s Date / //

The issuer of the card identified on this form is authorized to pay the amount(s) shown above. I agree to pay such amount(s) (together with any other charge due theron) subject to and in accordance with the agreement governing the use of such card.

The TICR Program will provide a refund (minus a $75 withdrawal fee) only if students request this within 24 hours of the 2nd lecture in the course.

Please return form to: / UCSF – Department of Epidemiology & Biostatistics
Attn: Patty Tan
Phone: 415-514-8097
OR
Via regular or commercial mail to: / 550 16th Street, 2nd Floor, Box 0560
San Francisco, CA 94143
(For commercial delivery, e.g., FedEx, use zip code 94158)
OR
Via campus mail to: / Box 0560
OR
Email to: /