Re: Membership in the Cardiac Safety Research Consortium

Dear :

On behalf of the CSRC we would like to thank you for your interest in joining the Cardiac Safety Research Consortium. We would be delighted to have you consider joining the consortium and invite you to complete the attached membership application at your earliest convenience. Please send your completed application electronically to .

There are several membership opportunities within the CSRC: 1) founding members, 2)sustainingmembers, 3) principal members, and 4)associate members. The Membership Committee will determine whether the member (individual, company, or organization) meets the criteria for full membership.

Full membership in the consortium for for-profit organizations requires a monetary contribution as follows:

Founding (No Longer Available) / Sustaining / Principal / Associate
Large Companies
market capitalization > $3 billion or yearly gross sales > $1 billion / $50,000 / $25,000/year with a 3 year commitment / $15,000 / $8,000
Medium Companies
market capitalization of $250 million to $3 billion or yearly gross sales of $50 million to $1 billion / $25,000 / $10,000/year with a 3 year commitment / $10,000 / $4,000
Small Companies
market capitalization < $250 million or yearly revenue < $50 million / $10,000 / $4,000/year with a 3 year commitment / $4,000 / $2,000
Start-up Companies
market capitalization of $0 AND yearly gross sales of $0 / $1,000

Annual dues will be required for all membership levels.

Members from for-profit companies/organizations will agree to participate in consortium activities and provide some type of contribution in-kind (e.g., technology, data, or expertise). In addition,founding/sustaining members are eligible for positions on CSRC governance committees. All members may attend CSRC meetings and participateon research teams.

We are very interested in finding a way for anyone interested to get involved in the work of the consortium. If you are interested in the work of the consortium and have any questions about how you can get involved, please us at .

Sincerely,

Theressa J. Wright, MD

Chair, Membership Committee, Cardiac Safety Research Consortium

Senior Director, Global Patient Safety Early Phase Medicine

Eli Lilly & Company
Lilly Corporate Center

Drop Code 2542

Indianapolis, Indiana 46285

Office: 317-277-3834
Mobile: 317-457-2076

Fax:317-655-2060

Email:

cc: Mitchell Krucoff, MD, FACC, Cardiac Safety Research Consortium Co-Chair

John K. Finkle, MD, FACP, FACC, Cardiac Safety Research Consortium Co-Chair

Attachment

Application for Membership to the Cardiac Safety Research Consortium

Instructions for completing form. The form can be completed and submitted electronically.

Please complete all information and attach relevant documentation as appropriate.

To determine planned contribution to CSRC as requested in #7, please use the following guidelines (as outlined in the CSRC membership charter):

Applications for founding members were closed on June 30, 2010.

These categories and their associated contributions are suggested. Additional criteria for membership include the contribution of data and manpower. Potential members that anticipate difficulty in making the suggested financial contributions are encouraged to contact the CSRC Membership Committee at for a consultation. The CSRC will consider proposed alternatives from groups wishing to join the consortium. The final decision on membership will be based upon the financial contribution and its justification, the level of anticipated involvement, and the type of contribution-in-kind set forth in the application.

If you have any questions regarding this form, please contact us .

1. Name of Applicant:
2. Organization andAddress:
3. E-mail:
4. Describe the category that best describes your organization or status as an individual:
Not-for-profit organization
For-profit company/organization (pharmaceutical corporations, contract research organizations, core laboratories, and technology companies)
Individual (cardiac safety consultants, advisors, academics, individuals from regulatory agencies)
5. Briefly describe your organization or your role as an individual interested in cardiac safety:
6. Briefly explain your interest in CSRC:
7. Briefly explain planned contribution to CSRC (check all that apply):
Financial (indicate $ amount of the contribution and justification for any variance with regard to the contribution levels outlined above)
$
Justification for variance (if applicable):
Data (describe whether you have access to and permission to share data with the consortium)
Expertise (describe the expertise you plan to bring to the work of the consortium)
Technology (describe any technology you plan to bring to the work of the consortium)
Other (Describe):
8. Please provide the names, CVs/resumes, and e-mail addresses of the individuals who will be participating in the CSRC.
Return completed application to .