Application

Please complete the following application form for SIC membership.

Are you applying for SIC membership as an organization or as an individual contributor?(Required)

First Name(Required)

Last Name(Required)

Suffix

Academic and/or professional credentials(Required)

Email address(Required)

LinkedIn profile

Please upload your CV(Required)

Max. file size: 128 MB.

Organization Name(Required)

Organization Billing Street Address 1(Required)

Organization Billing Street Address 2

Organization Billing City(Required)

Organization Billing State/Province(Required)

Organization Billing ZIP Code(Required)

Organization Primary Email Address (for billing purposes)(Required)

Select the category that best describes your organization(Required)

Select total organization annual sales(Required)

Please enter organization Federal EIN/Tax ID Number(Required)

Please enter the organization's total annual revenue (last fiscal year) (numeric values only)(Required)

Please describe your organization's interest in SIC and areas of interest(Required)

(e.g., antimicrobial resistance, clinical care, equity, host-directed therapeutics, medical devices, pediatric sepsis, etc.)

Organizational Contact First Name(Required)

Organizational Contact Last Name(Required)

Organizational Contact Suffix

Organizational Contact Title(Required)

Organizational Contact Email Address(Required)

Organizational Contact Phone Number

I would like to sign up for updates from Sepsis Innovation Collaborative(Required)

Yes

I would like to sign up for updates from Sepsis Alliance(Required)

Yes