Application for Membership

To be considered for membership, please provide evidence of peer-reviewed grant support and/or evidence of patient care and teaching activities (for example, NIH Biosketch/curriculum vitae and Other supportingpages) to this form. You may mail materials with a copy of this form to: LHI Membership, Room 120 DVCCRC MMC #195, 420 Delaware St. SE, Minneapolis, MN 55455. You may also fax to 612-625-0404, or e-mail electronic files to lhi@umn.edu. Required fields are marked with a *.
*First Name:	*Last Name:	MI:

Degree (i.e. M.D., Ph.D., etc.):

Title:

Affiliation: (school/college, department, division)

*Designation:

Office Location: Room #:	Bldg.:

Mailing Address: Box or Room #:	Bldg. Abbrev:

*Telephone:	FAX:

*Email

Non-University Business Address (if applicable)

Areas of Interest Please select a Primary Area of Interest. If you wish, you may also select a secondary and additional area of interest.

Briefly state your current specific area of scientific interest or expertise.

Identify any comments or suggestions for LHI:

	Reminder: please provide evidence of peer-reviewed grant support and/or evidence of patient care and teaching activities (see note at the top of the page).

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