Organizational Membership Application

Health Research Organizational Membership Alliance Application Complete the application and return it by email to: [email protected]. You will be invoiced separately for dues upon acceptance for membership.

Organizational Information

Name of Organization:

Acceptable Acronym: Website URL:

Mailing Address: ( include street address as well as P.O. Box ) Main Phone Number:

Fax Number:

Person we should contact with any questions about this application:

Name: Phone: Email:

Type of Organization

Private foundation: ____ Provide IRS tax identiﬁcation number:

Public charity: ____ Provide IRS tax identiﬁcation number:

Other: ____ Provide IRS tax identiﬁcation number:

Additional Information to be Provided ( this material can be attached ) Brief description of mission and purpose of organization:

Brief description of organization’s funding of biomedically relevant research and/or biomedically relevant research training programs

Brief description of the process used to select awardees, especially how the scientific merit of the applications is evaluated. Briefly note the membership and role of any scientific review committee (internal and external), criteria for evaluation (high level), how ﬁnal decisions are made, and how reviewer conﬂicts of interest are managed.

Is the organization’s Annual Report available? No ___ Yes____ Most recent is attached or the URL is:

Does the organization list its awards/grants annually on its website?

8/2017 page 1 of 2 No ___ Yes____ The URL is:

Dues are determined by the table below. New members are invoiced for dues at the time of joining the Alliance and then are invoiced annually in the ﬁrst quarter of the calendar year, with payment due in March.

1 2 If the total of all health-related grants paid in Annual Health Research Alliance dues are: the most recently-completed ﬁscal year is: Up to $ 4.9 M $ 2,500 $ 5 M - $ 9.9 M $ 3,125 $10 M - $19.9 M $ 6,250 $20 M - $39.9 M $10,000 $40 M - $59.9 M $12,500 $60 M - $79.9 M $18,750 $80 M or more $25,000

1 The phrase “all health-related grants” includes all grants made for biomedically relevant research, education and training. 2 The phrase “grants paid” means cash out the door in that ﬁscal year, regardless of when the grant was awarded.

Our organization’s most recently-completed ﬁscal year ended on: / / Month Day Year The total of all health-related grants paid in that ﬁscal year was:

Based on the table above, my organization’s dues are:

To apply, complete the application and return by email to [email protected]

You should receive notiﬁcation regarding the status of your application within four weeks of submission of this completed application and your organization will be invoiced separately for dues.

Health Research Alliance 65 T. W. Alexander Dr. #13605 Research Triangle Park, NC 27709-3901

8/2017 page 1 of 2 (919) 867-1678 [email protected]

8/2017 page 1 of 2