App Form List of Industry-Independent Medical Experts
This is the form for submitting updated contact information for The List, as well as the application for new members. Please answer all the relevant questions, even if you are already on the list in a previous format: having your contact information in the new system will prevent us from contacting you unnecessarily.
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Email *
First Name *
Last Name *
Title *
Required
Academic title (professor, clinical adjunct, etc.)
If relevant
Affiliation
If you would like to list your organizational affiliation(s), please fill in the name of the organization in the box. If you don't want to list them, just leave it blank.
Country *
Country if "Other"
City or Province: *
Availability for media *
Names of two references with email or phone contact information. If you have references from current List members, please include them.
Preferred method of contact? *
Contact information: Email
Enter your email address here if this is your preferred method of contact, and please answer AT LEAST ONE of the contact questions  (cell/office/other contact information options follow):
Contact information: Cell Phone
Contact information: Office Phone
Contact information: Home/Other Phone
Please do not list fax numbers.
Website
If you have a related website you'd like to list, please enter here
Area(s) of clinical expertise: *
Select only areas where you would feel qualified to comment on the record and enter subspecialty under "Other" and you may elaborate further under the question below "Description of Interests"
Required
Other area(s) of expertise
Description of interests/expertise
If you want to elaborate on your areas of interest, research or expertise, do so here (optional):
Are you already a list member? *
Do you want to be on (or remain on) The List? *
Required
Disclosures: List disclosures for eligibility to be listed on Page 2.
If you are uncertain about whether your disclosures comprise a conflict of interest, simply list here and the panel will respond.  If you have no disclosures to make, please LEAVE THIS QUESTION BLANK.
Questions or Comments?
A copy of your responses will be emailed to the address you provided.
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