Post a Provider on CenterWatch

Post an Industry Provider Profile Page on the CenterWatch Web Site

Please complete each section of this template in order to set-up your Industry Provider Profile Page on the CenterWatch web site. When you're through, click "submit."

Enter your name, phone number, and email address in the space provided here, so that we may contact you should we have any questions about the information you've completed below.

Please use the tab button to move to the next field. Please complete the entire form before submitting.

Items marked with an asterisk ** are required.

Template Submitted by:

	Name:
	Phone Number:
	E-Mail Address:

PART I: CenterWatch Representative

In the menu below, please select the name of your CenterWatch contact/salesperson:

PART II: Contact Information for Industry Provider Profile Page

Complete this information as you'd like it to appear on your profile page. (Please include only one set of contact information.)

	Company Name:**
	Name:**
	Title:
	Address:**
	City:**
	State:**
	Zip:**
	Country:**
	Phone:**
	Fax:
	E-mail address:
	Center's Home Page Address (if applicable):

PART III: Services

For each of the following categories, check all of the services that your company offers:

	I. Preclinical Services
	Medicinal & organic chemistry
	Biological & pharmacological research
	Animal testing
	Laboratory services
	Quality assurance & compliance

	II. Phase I Services
	First-time-in-man studies
	Bioequivalence studies
	Bioavailability studies
	Pharmacokinetics/ pharmacodymanic studies

	III. Phase II & Phase III Services
	Project Management		Protocol & CRF development
	Clinical trials design		Clinical packaging & supplies services
	Clinical trials monitoring services		Investigative site selection & management
	Patient recruitment		Laboratory services
	Biometric and hematologic services		Statistical services
	Data management & analysis		Drug dosage & formulation services
	Quality assurance & control services

	IV. Regulatory Services
	Regulatory Affairs
	Document, manuscript, and CANDA preparation
	IND submission
	NDA submission
	Regulatory consulting

	V. Post-Marketing Services
	Outcome measurement services
	Pharmacoeconomics studies
	Quality of life studies
	Rx-OTC studies
	Consumer testing services

	VI. Other Services
	Human resource training & education services
	Clinical research technologies
	Clinical research staffing services
	Business consulting service

PART IV: Type of Company

Please check off the category that best represents your company "type". If necessary, you may check off multiple categories or add an additional category in the space provided.

	Biotechnology Company		Medical or Research Education
	Communications		Site Management Organization (SMO)
	Contract Research Organization (CRO)		Packaging / Labeling
	Institutional Review Board (IRB)		Pharmaceutical Company
	Investigative Site / Investigative Consortium		Staffing / Recruiting / Executive Search
	Laboratory Services		Technology Solutions
	Management Consulting		Trial Management Organization (TMO)
	Medical Device Company		Other
	Patient Recruitment Company

PART V: Creating Your Profile Page Content

Please create the text to appear on your profile page. Your Industry Provider Profile Page text may include up to 8 sections, and there is no limit to the amount of text you may put in each section. The following are suggestions for possible section topics. You may use them and / or create your own:

· Company Overview
Company history; description of organization; staff information; mission statement
· Products and Services
Description of the services and products offered by your company
· Facilities
List of any branch offices or additional locations; description of any unique characteristics of your facilities
· Clients and Customers
Description of the companies / individuals for whom you provide services

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PART VI: Personalizing the URL Address of Your Profile

Choose a "pseudonym" to appear in the URL address of your profile page.

Example of personalized URL format: www.centerwatch.com/JoeSchmoResearchConsultants

Type your "pseudonym" in the space provided here. (Use only letters and numbers. No punctuation or spaces, please.)

www.centerwatch.com/

PART VII: Company Logo / Graphic

You may customize your page further by having your corporate logo appear at the top of your profile. Please choose one of the following options:

	We have a logo in electronic format. Please instruct us as to how to submit our logo to you.
	We do not have a logo in electronic format, but would like to learn about how you can create one for us for an additional fee.
	We would not like a logo to appear on our page at this time.

PART VIII: CenterWatch Billing Information

The profile page service begins from the time we post your profile as a demo page. At that time, an invoice will be sent to the contact that you provided on your submission. Payment is due within thirty days after the receipt of the invoice.

	I agree to pay the $275 one-time setup fee, plus the $750/year annual membership fee

	Please note any special offer code here:

	Please note: The annual service and fee will renew automatically at the end of the annual term as long as your profile page is still posted. For more information, please refer to our Terms & Conditions.

Purchase Order Information:

Do we need a PO Number from your company in order to bill you?

	Yes
	No

If so, please type PO Number here:

Billing Contact Information:

	Billing contact is same as contact listed above.
	Billing contact is different than contact listed above.

If different, please complete information below:

	Billing Contact Name:
	Title:
	Billing Address:
	City:
	State:
	Zip Code:
	Country:
	Phone:
	Fax:
	E-mail:

PART IX: Additional Comments

Use the space below to provide any additional comments or questions regarding your provider page. Please specify whether or not you'd like to be contacted to discuss these comments further.

Type your additional information here:

PART X: Terms & Conditions

Please Click here to view the terms and conditions of posting your profile on the CenterWatch web site.

**By clicking here, I agree to the terms and conditions of posting my profile on CenterWatch.

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