Certification

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Become a CCDM Industry Partner

Please complete this application to participate in the 2011 Society for Clinical Data Management CCDM® Industry Partner Program

* Organization name:

* Address:

* City:

* State:

* Zip code:

* Administrative contact name:

* Administrative contact title:

* Administrative contact email:

* Administrative contact phone:

Total number of Clinical Data Managers, including CCDMs, employed by your organization at location who are eligible to sit for the exam:

Additional Contacts
Marketing, business development or other company representatives who should receive program updates, press releases and other materials related to your company’s participation in this program.

Name

Title

E-mail

Mailing Address

Phone

Name

Title

E-mail

Mailing Address

Phone

Enter the names of your organization's Certified Clinical Data Managers (CCDMs), or upload your own roster of CCDMs.

If you are uploading a file, please name it with your company name and no punctuation (Example: companyname_roster.xls)

1. First name:	Last name:
Title:

2. First name:	Last name:
Title:

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