Group Membership


Final C3 logo

Referred By (if any):

Agreement

The Group Membership Application Agreement (“Agreement”) is made by and between Clinical Care Continuum (“C3”) and (“Applicant”) effective as of:
(current date).

Name of individual who nominated you:
(If nomination by self please state “self-nominated”)

Legal Name of Applicant:

Legal Name of Place of Employment/Affiliated Practice:

Address:

City:

State:

Zip Code:

Phone:

Email Address:

DEA License or Caregiver Certification:

Medical Specialty:

Practice Information (if applicable)

By providing fax number, email and signing this agreement, Member hereby grants C3 permission to contact Member via fax or email in order to pass on information regarding educational meetings, product announcements, and/or any other information that C3 deems may be of interest to Member, consistent with the requirements set forth in the Junk Fax Prevention Act of 2005.

Legal Name of Practice:

Tax ID:

Address:

City:

State:

Zip Code:

Number of Providers in Practice:

Phone:

Fax:

Medical Director:

Name:

Phone:

Office Contact:

Title:

Email:

If there are additional office locations, please fax a separate sheet with address, telephone and fax numbers.


Physician Name

DEA Number

Medical Specialty

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Key Opinion Leader Questions

What medical societies and organizations do you currently belong to?

Please list any speaker appointments within the pharmaceutical, biotechnology or healthcare related fields.

What leadership positions have you held within medical and community based organizations?

Please list any publications you authored with medical journals.

Please provide any experience in clinical research.

Please provide your specialty or any area of expertise.

Signature and Certification

By submitting the following application information and signing this Agreement, Applicant agrees to enroll as a Member of C3. C3 will notify you once you have been approved to enroll as a Member.

Annual membership fee for C3 Basic Level is $299 per physician per year, as well as a one-time $49.99 activation and setup fee per physician. Provider Practice membership is $200 per physician for 4 or more physicians. Make check payable to C3. Membership payment should be mailed to:

C3 Membership
116 Wilson Pike Circle Suite 240
Fax: 615-730-8475
Brentwood, TN 37027

Provider Signature (Please enter your name, this is considered your electronic signature):

Title:

Date:

Please remember which email address you have used on the above form, as you will use the same one on the following payment page. This email address will be used as our reference to your membership application and payment, and it is important that they are the same, otherwise processing of your application may be delayed or rejected.