APEX Membership Application

APEX Membership Application

Membership application for the American Porphyrias Expert Collaborative. Complete the fields that apply to your membership type and sign the attestation at the end.
Membership Type

https://www.apexcollaborative.com/become-a-member
Membership type
Applicant Information
Full Name

First NameLast Name
Credentials
Attach CV

PDF, DOC, or DOCX only.
Cancelof
Professional Title
Institution/Organization
Department/Division
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Email Address
example@example.com
Phone Number

Country CodeArea CodePhone Number
Years of porphyria or heme biosynthesis experience
Primary area of expertise

Other
Porphyria types you specialize in

Other
Expert and Associate Expert Member Details
Why are you seeking APEX membership, and what do you hope to contribute to the collaborative?
Current porphyria center affiliation, if applicable
Director, Co-Director, or Associate Director of a Porphyria Center of Expertise
Number of qualifying peer-reviewed publications
List up to five representative peer-reviewed publications relevant to porphyria or heme biosynthesis
List the publications for the author categories you select from below.
Author categories
Affiliate Member Details
Name and title of supervising Director, Co-Director, or Associate Director
Role at the center
Description of how current work involves the diagnosis, treatment, or management of porphyrias or heme synthesis
Industry/Corporate Member Details
Brief description of the organization's activities related to porphyria diagnosis or treatment
Type of organization

Other
Primary contact name and title
Final Attestation
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Confirmation
Should be Empty:

APEX Membership Application

Membership Type

Applicant Information

Expert and Associate Expert Member Details

Affiliate Member Details

Industry/Corporate Member Details

Final Attestation