University of Washington - Diabetes Research Center Diabetes Research Center Application for Affiliate Status

Project Title*

Date

First Name*

Middle Initial*

Last Name*

Degrees*

Academic Title*

University/Organization*

School*

Department*

Division*

Site (Non-UW Faculty: Mailing Address)*

Box (Non-UW Faculty: City/State/Zip Code)*

Phone*

Email*

Co-Investigator(s)/Collaborator(s)

First Name	Middle Initial	Last Name	Academic Title	Departmental Affiliations

Current Research Funding*

Agency	Award Number	Award Title	Principal Investigator	Award Period	Direct Costs

Cores to be utilized (check all that are applicable)*

Research Base (Primary)*

Research Base (Secondary)

Describe, in general terms (1-2 sentences), the core services you plan to use*

Project summary (short paragraph) and how it relates to diabetes or obesity*

Research interests*

Upload your C.V.*

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