Institution Name   Required

Name of Responsible Officer

     Title

Liaison Coordinator Name   Required

     Title

Address Line 1

Address Line 2

Address Line 3

City

State or Province

Postal Code

Country

Telephone    Fax

E-mail

If you are writing to sign on as a new Participating Institution or Liaison Coordinator, please read our Guidelines for Participating Institutions and sign the following agreement: "We hereby declare that we are willing to abide by the provisions and expectations governing participating institutions and liaison coordinators, as outlined in the Guidelines."        Signature: * *Entering your name or initials in this space serves as your "electronic signature."