UM CACPR Membership Application Form

<!DOCTYPE html> <html class="msie msie7" id="" lang="en"> <head> <title> UM CACPR Membership Application Form </title>  <meta charset="utf-8"> <meta name="generator" content="Wufoo"> <meta name="robots" content="index"> <meta name="viewport" content="width=device-width, initial-scale=1">  <script src="https://cdn.signalfx.com/o11y-gdi-rum/latest/splunk-otel-web.js" crossorigin="anonymous"></script> <script> SplunkRum.init({ beaconUrl: 'https://rum-ingest.us1.signalfx.com/v1/rum', rumAuth: 'zQDdp67Bj5femMun0rlk_w', app: 'wufoo_web', environment: 'prod', instrumentations: { errors: true }, tracer: { sampler: new SplunkRum.SessionBasedSampler({ ratio: 0.1 }), }, }); </script>  <meta property="twitter:card" content="summary"/> <meta property="twitter:site" content="@Wufoo"/> <meta property="og:url" content="https://umbforms.wufoo.com/forms/r16wdfb91e59u7b/"/> <meta property="og:type" content="website"/> <meta property="og:title" content="UM CACPR Membership Application Form"/> <meta 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target="_blank" title="Powered by Wufoo">Wufoo</a> </h1> <form id="form415" name="form415" class="wufoo topLabel page1" accept-charset="UTF-8" autocomplete="off" enctype="multipart/form-data" method="post" novalidate action="https://umbforms.wufoo.com/forms/r16wdfb91e59u7b" > <header id="header" class="info"> <h2 class="">UM CACPR Membership Application Form</h2> <div class=""></div> </header> <ul> <li id="fo415li1" class="notranslate "> <label class="desc" id="title1"> Name <span id="req_1" class="req">*</span> </label> <span> <input id="Field1" name="Field1" type="text" class="field text fn" value="" size="8" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field1">First</label> </span> <span> <input id="Field2" name="Field2" type="text" class="field text ln" value="" size="14" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field2">Last</label> </span> </li> <li id="fo415li126" class="notranslate "> <label class="desc" id="title126" for="Field126"> Email <span id="req_126" class="req">*</span> </label> <div> <input id="Field126" name="Field126" type="email" spellcheck="false" class="field text medium" value="" maxlength="255" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> </div> </li> <li id="fo415li4" class="notranslate "> <label class="desc" id="title4" for="Field4"> Degree(s) <span id="req_4" class="req">*</span> </label> <div> <textarea id="Field4" name="Field4" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="0" onkeyup="handleInput(this); validateRange(4, 'character');" onchange="handleInput(this);" placeholder="" required ></textarea> </div> </li> <li id="fo415li5" data-wufoo-field data-field-type="text" class="notranslate "> <label class="desc" id="title5" for="Field5"> Position <span id="req_5" class="req">*</span> </label> <div> <input id="Field5" name="Field5" type="text" class="field text medium" value="" maxLength="255" tabindex="0" onkeyup="handleInput(this); " onchange="handleInput(this);" required placeholder="" /> </div> </li> <li id="fo415li6" data-wufoo-field data-field-type="text" class="notranslate "> <label class="desc" id="title6" for="Field6"> Department <span id="req_6" class="req">*</span> </label> <div> <input id="Field6" name="Field6" type="text" class="field text medium" value="" maxLength="255" tabindex="0" onkeyup="handleInput(this); " onchange="handleInput(this);" required placeholder="" /> </div> </li> <li id="fo415li7" class="notranslate "> <label class="desc" id="title7" for="Field7"> Research Interests <span id="req_7" class="req">*</span> </label> <div> <textarea id="Field7" name="Field7" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="0" onkeyup="handleInput(this); validateRange(7, 'character');" onchange="handleInput(this);" placeholder="" required ></textarea> </div> <p class="instruct" id="instruct7"> <small>Short description (up to 5 bullet points)</small> </p> </li> <li id="fo415li8" class="notranslate "> <label class="desc" id="title8" for="Field8"> Research approaches/Methods <span id="req_8" class="req">*</span> </label> <div> <textarea id="Field8" name="Field8" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="0" onkeyup="handleInput(this); validateRange(8, 'character');" onchange="handleInput(this);" placeholder="" required ></textarea> </div> <p class="instruct" id="instruct8"> <small>(e.g. electrophysiology, molecular biology, pain phenotyping)</small> </p> </li> <li id="fo415li9" data-wufoo-field data-field-type="text" class="notranslate "> <label class="desc" id="title9" for="Field9"> ORCID ID <span id="req_9" class="req">*</span> </label> <div> <input id="Field9" name="Field9" type="text" class="field text medium" value="" maxLength="255" tabindex="0" onkeyup="handleInput(this); " onchange="handleInput(this);" required placeholder="" /> </div> </li> <li id="fo415li10" data-wufoo-field data-field-type="text" class="notranslate "> <label class="desc" id="title10" for="Field10"> Link to lab or individual webpage </label> <div> <input id="Field10" name="Field10" type="text" class="field text medium" value="" maxLength="255" tabindex="0" onkeyup="handleInput(this); " onchange="handleInput(this);" placeholder="" /> </div> </li> <li id="fo415li11" class="notranslate "> <label class="desc" id="title11" for="Field11"> List up to five publications (within the last five years): </label> <div> <textarea id="Field11" name="Field11" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="0" onkeyup="handleInput(this); validateRange(11, 'character');" onchange="handleInput(this);" placeholder="" ></textarea> </div> </li> <li id="fo415li12" class=" "> <fieldset> <![if !IE | (gte IE 8)]> <legend id="title12" class="desc notranslate"> Membership level you are applying for: <span id="req_12" class="req">*</span> </legend> <![endif]>  <div> <input id="radioDefault_12" name="Field12" type="hidden" value="" /> <span> <input id="Field12_0" name="Field12" type="radio" class="field radio" value="Regular" tabindex="0" onchange="handleInput(this);" onmouseup="handleInput(this);" required /> <label class="choice" for="Field12_0" > <span class="choice__text notranslate">Regular</span> <span class="choice__qty"> </span> </label> </span> <span> <input id="Field12_1" name="Field12" type="radio" class="field radio" value="Trainee" tabindex="0" onchange="handleInput(this);" onmouseup="handleInput(this);" required /> <label class="choice" for="Field12_1" > <span class="choice__text notranslate">Trainee</span> <span class="choice__qty"> </span> </label> </span> </div> </fieldset> </li> <li id="fo415li13" class="notranslate " > <label class="desc" id="title13" for="Field13"> Please upload a head shot photo or other appropriate images </label> <div> <input id="Field13" name="Field13" type="file" class="field file" size="12" data-file-max-size="10" tabindex="0" data-wufoo-field="file-upload" /> </div> </li> <li id="fo415li14" class="notranslate " > <label class="desc" id="title14" for="Field14"> Attach a File </label> <div> <input id="Field14" name="Field14" type="file" class="field file" size="12" data-file-max-size="10" tabindex="0" data-wufoo-field="file-upload" /> </div> </li> <li id="fo415li15" class="notranslate " > <label class="desc" id="title15" for="Field15"> Attach a File </label> <div> <input id="Field15" name="Field15" type="file" class="field file" size="12" data-file-max-size="10" tabindex="0" data-wufoo-field="file-upload" /> </div> </li> <li id="fo415li119" class="complex notranslate "> <label class="desc" id="title119"> Address <span id="req_119" class="req">*</span> </label> <div> <span class="full addr1"> <input id="Field119" name="Field119" type="text" class="field text addr" value="" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field119">Street Address</label> </span> <span class="full addr2"> <input id="Field120" name="Field120" type="text" class="field text addr" value="" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" /> <label for="Field120">Address Line 2</label> </span> <span class="left city"> <input id="Field121" name="Field121" type="text" class="field text addr" value="" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field121">City</label> </span> <span class="right state"> <input id="Field122" name="Field122" type="text" class="field text addr" value="" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field122">State / Province / Region</label> </span> <span class="left zip"> <input id="Field123" name="Field123" type="text" class="field text addr" value="" maxlength="15" tabindex="0" onkeyup="handleInput(this);" onchange="handleInput(this);" placeholder="" required /> <label for="Field123">Postal / Zip Code</label> </span> <span class="right country"> <select id="Field124" name="Field124" class="field select addr" tabindex="0" onchange="handleInput(this);" onkeyup="handleInput(this);" data-wufoo-field="dropdown" > <option value="" selected="selected"></option> <option value="United States" >United States</option> <option value="United Kingdom" >United Kingdom</option> <option value="Australia" >Australia</option> <option value="Canada" >Canada</option> <option value="France" >France</option> <option value="New Zealand" >New Zealand</option> <option value="India" >India</option> <option value="Brazil" >Brazil</option> <option value="----" >----</option> <option value="Afghanistan" >Afghanistan</option> <option value="脜land Islands" >脜land Islands</option> <option value="Albania" >Albania</option> <option value="Algeria" >Algeria</option> <option value="American Samoa" >American Samoa</option> <option value="Andorra" >Andorra</option> <option value="Angola" >Angola</option> <option value="Anguilla" >Anguilla</option> <option value="Antarctica" >Antarctica</option> <option value="Antigua & Barbuda" >Antigua & Barbuda</option> <option value="Argentina" >Argentina</option> <option value="Armenia" >Armenia</option> <option value="Aruba" >Aruba</option> <option value="Austria" >Austria</option> <option value="Azerbaijan" >Azerbaijan</option> <option value="Bahamas" >Bahamas</option> <option value="Bahrain" >Bahrain</option> <option value="Bangladesh" >Bangladesh</option> <option value="Barbados" >Barbados</option> <option value="Belarus" >Belarus</option> <option value="Belgium" >Belgium</option> <option value="Belize" >Belize</option> <option value="Benin" >Benin</option> <option value="Bermuda" >Bermuda</option> <option value="Bhutan" >Bhutan</option> <option value="Bolivia" >Bolivia</option> <option value="Bosnia & Herzegovina" >Bosnia & Herzegovina</option> <option value="Botswana" >Botswana</option> <option value="Bouvet Island" >Bouvet Island</option> <option value="British Indian Ocean Territory" >British Indian Ocean Territory</option> <option value="British Virgin Islands" >British Virgin Islands</option> <option value="Brunei" >Brunei</option> <option value="Bulgaria" >Bulgaria</option> <option value="Burkina Faso" >Burkina Faso</option> <option value="Burundi" >Burundi</option> <option value="Cambodia" >Cambodia</option> <option value="Cameroon" >Cameroon</option> <option value="Cape Verde" >Cape Verde</option> <option value="Caribbean Netherlands" >Caribbean Netherlands</option> <option value="Cayman Islands" >Cayman Islands</option> <option value="Central African Republic" >Central African Republic</option> <option value="Chad" >Chad</option> <option value="Chile" >Chile</option> <option value="China" >China</option> <option value="Christmas Island" >Christmas Island</option> <option value="Cocos (Keeling) Islands" >Cocos (Keeling) Islands</option> <option value="Colombia" >Colombia</option> <option value="Comoros" >Comoros</option> <option value="Congo - Brazzaville" >Congo - Brazzaville</option> <option value="Congo - Kinshasa" >Congo - Kinshasa</option> <option value="Cook Islands" >Cook Islands</option> <option value="Costa Rica" >Costa Rica</option> <option value="C么te d鈥橧voire" >C么te d鈥橧voire</option> <option value="Croatia" >Croatia</option> <option value="Cuba" >Cuba</option> <option value="Cura莽ao" >Cura莽ao</option> <option value="Cyprus" >Cyprus</option> <option value="Czechia" >Czechia</option> <option value="Denmark" >Denmark</option> <option value="Djibouti" >Djibouti</option> <option value="Dominica" >Dominica</option> <option value="Dominican Republic" >Dominican Republic</option> <option value="Ecuador" >Ecuador</option> <option value="Egypt" >Egypt</option> <option value="El Salvador" >El Salvador</option> <option value="Equatorial Guinea" >Equatorial Guinea</option> <option value="Eritrea" >Eritrea</option> <option value="Estonia" >Estonia</option> <option value="Ethiopia" >Ethiopia</option> <option value="Falkland Islands" >Falkland Islands</option> <option value="Faroe Islands" >Faroe Islands</option> <option value="Fiji" >Fiji</option> <option value="Finland" >Finland</option> <option value="French Guiana" >French Guiana</option> <option value="French Polynesia" >French Polynesia</option> <option value="French Southern Territories" >French Southern Territories</option> <option value="Gabon" >Gabon</option> <option value="Gambia" >Gambia</option> <option value="Georgia" >Georgia</option> <option value="Germany" >Germany</option> <option value="Ghana" >Ghana</option> <option value="Gibraltar" >Gibraltar</option> <option value="Greece" >Greece</option> <option value="Greenland" >Greenland</option> <option value="Grenada" >Grenada</option> <option value="Guadeloupe" >Guadeloupe</option> <option value="Guam" >Guam</option> <option value="Guatemala" >Guatemala</option> <option value="Guernsey" >Guernsey</option> <option value="Guinea" >Guinea</option> <option value="Guinea-Bissau" >Guinea-Bissau</option> <option value="Guyana" >Guyana</option> <option value="Haiti" >Haiti</option> <option value="Heard & McDonald Islands" >Heard & McDonald Islands</option> <option value="Honduras" >Honduras</option> <option value="Hong Kong SAR China" >Hong Kong SAR China</option> <option value="Hungary" >Hungary</option> <option value="Iceland" >Iceland</option> <option value="Indonesia" >Indonesia</option> <option value="Iran" >Iran</option> <option value="Iraq" >Iraq</option> <option value="Ireland" >Ireland</option> <option value="Isle of Man" >Isle of Man</option> <option value="Israel" >Israel</option> <option value="Italy" >Italy</option> <option value="Jamaica" >Jamaica</option> <option value="Japan" >Japan</option> <option value="Jersey" >Jersey</option> <option value="Jordan" >Jordan</option> <option value="Kazakhstan" >Kazakhstan</option> <option value="Kenya" >Kenya</option> <option value="Kiribati" >Kiribati</option> <option value="Kosovo" >Kosovo</option> <option value="Kuwait" >Kuwait</option> <option value="Kyrgyzstan" >Kyrgyzstan</option> <option value="Laos" >Laos</option> <option value="Latvia" >Latvia</option> <option value="Lebanon" >Lebanon</option> <option value="Lesotho" >Lesotho</option> <option value="Liberia" >Liberia</option> <option value="Libya" >Libya</option> <option value="Liechtenstein" >Liechtenstein</option> <option value="Lithuania" >Lithuania</option> <option value="Luxembourg" >Luxembourg</option> <option value="Macau SAR China" >Macau SAR China</option> <option value="Republic of North Macedonia" >Republic of North Macedonia</option> <option value="Madagascar" >Madagascar</option> <option value="Malawi" >Malawi</option> <option value="Malaysia" >Malaysia</option> <option value="Maldives" >Maldives</option> <option value="Mali" >Mali</option> <option value="Malta" >Malta</option> <option value="Marshall Islands" >Marshall Islands</option> <option value="Martinique" >Martinique</option> <option value="Mauritania" >Mauritania</option> <option value="Mauritius" >Mauritius</option> <option value="Mayotte" >Mayotte</option> <option value="Mexico" >Mexico</option> <option value="Micronesia" >Micronesia</option> <option value="Moldova" >Moldova</option> <option value="Monaco" >Monaco</option> <option value="Mongolia" >Mongolia</option> <option value="Montenegro" >Montenegro</option> <option value="Montserrat" >Montserrat</option> <option value="Morocco" >Morocco</option> <option value="Mozambique" >Mozambique</option> <option value="Myanmar (Burma)" >Myanmar (Burma)</option> <option value="Namibia" >Namibia</option> <option value="Nauru" >Nauru</option> <option value="Nepal" >Nepal</option> <option value="Netherlands" >Netherlands</option> <option value="New Caledonia" >New Caledonia</option> <option value="Nicaragua" >Nicaragua</option> <option value="Niger" >Niger</option> <option value="Nigeria" >Nigeria</option> <option value="Niue" >Niue</option> <option value="Norfolk Island" >Norfolk Island</option> <option value="North Korea" >North Korea</option> <option value="Northern Mariana Islands" >Northern Mariana Islands</option> <option value="Norway" >Norway</option> <option value="Oman" >Oman</option> <option value="Pakistan" >Pakistan</option> <option value="Palau" >Palau</option> <option value="Palestinian Territories" >Palestinian Territories</option> <option value="Panama" >Panama</option> <option value="Papua New Guinea" >Papua New Guinea</option> <option value="Paraguay" >Paraguay</option> <option value="Peru" >Peru</option> <option value="Philippines" >Philippines</option> <option value="Pitcairn Islands" >Pitcairn Islands</option> <option value="Poland" >Poland</option> <option value="Portugal" >Portugal</option> <option value="Puerto Rico" >Puerto Rico</option> <option value="Qatar" >Qatar</option> <option value="R茅union" >R茅union</option> <option value="Romania" >Romania</option> <option value="Russia" >Russia</option> <option value="Rwanda" >Rwanda</option> <option value="Samoa" >Samoa</option> <option value="San Marino" >San Marino</option> <option value="S茫o Tom茅 & Pr铆ncipe" >S茫o Tom茅 & Pr铆ncipe</option> <option value="Saudi Arabia" >Saudi Arabia</option> <option value="Senegal" >Senegal</option> <option value="Serbia" >Serbia</option> <option value="Seychelles" >Seychelles</option> <option value="Sierra Leone" >Sierra Leone</option> <option value="Singapore" >Singapore</option> <option value="Sint Maarten" >Sint Maarten</option> <option value="Slovakia" >Slovakia</option> <option value="Slovenia" >Slovenia</option> <option value="Solomon Islands" >Solomon Islands</option> <option value="Somalia" >Somalia</option> <option value="South Africa" >South Africa</option> <option value="South Georgia & South Sandwich Islands" >South Georgia & South Sandwich Islands</option> <option value="South Korea" >South Korea</option> <option value="South Sudan" >South Sudan</option> <option value="Spain" >Spain</option> <option value="Sri Lanka" >Sri Lanka</option> <option value="St. Barth茅lemy" >St. Barth茅lemy</option> <option value="St. Helena" >St. Helena</option> <option value="St. Kitts & Nevis" >St. Kitts & Nevis</option> <option value="St. Lucia" >St. Lucia</option> <option value="St. Martin" >St. Martin</option> <option value="St. Pierre & Miquelon" >St. Pierre & Miquelon</option> <option value="St. Vincent & Grenadines" >St. Vincent & Grenadines</option> <option value="Sudan" >Sudan</option> <option value="Suriname" >Suriname</option> <option value="Svalbard & Jan Mayen" >Svalbard & Jan Mayen</option> <option value="Swaziland" >Swaziland</option> <option value="Sweden" >Sweden</option> <option value="Switzerland" >Switzerland</option> <option value="Syria" >Syria</option> <option value="Taiwan" >Taiwan</option> <option value="Tajikistan" >Tajikistan</option> <option value="Tanzania" >Tanzania</option> <option value="Thailand" >Thailand</option> <option value="Timor-Leste" >Timor-Leste</option> <option value="Togo" >Togo</option> <option value="Tokelau" >Tokelau</option> <option value="Tonga" >Tonga</option> <option value="Trinidad & Tobago" >Trinidad & Tobago</option> <option value="Tunisia" >Tunisia</option> <option value="Turkey" >Turkey</option> <option value="Turkmenistan" >Turkmenistan</option> <option value="Turks & Caicos Islands" >Turks & Caicos Islands</option> <option value="Tuvalu" >Tuvalu</option> <option value="U.S. Outlying Islands" >U.S. Outlying Islands</option> <option value="U.S. Virgin Islands" >U.S. Virgin Islands</option> <option value="Uganda" >Uganda</option> <option value="Ukraine" >Ukraine</option> <option value="United Arab Emirates" >United Arab Emirates</option> <option value="Uruguay" >Uruguay</option> <option value="Uzbekistan" >Uzbekistan</option> <option value="Vanuatu" >Vanuatu</option> <option value="Vatican City" >Vatican City</option> <option value="Venezuela" >Venezuela</option> <option value="Vietnam" >Vietnam</option> <option value="Wallis & Futuna" >Wallis & Futuna</option> <option value="Western Sahara" >Western Sahara</option> <option value="Yemen" >Yemen</option> <option value="Zambia" >Zambia</option> <option value="Zimbabwe" >Zimbabwe</option> </select> <label for="Field124">Country</label> </span> </div> </li> <li class="buttons "> <div> <input type="hidden" name="currentPage" id="currentPage" value="9x5IRGVDiwuBe9xNC8r8xJeACndwuslashiLUKv1MASaDk5fdg0k=" /> <input id="saveForm" name="saveForm" class="btTxt submit" type="submit" value="Submit" onmousedown="doSubmitEvents();" /> </div> </li> <li class="hide"> <label for="comment">Do Not Fill This Out</label> <textarea name="comment" id="comment" rows="1" cols="1"></textarea> <input type="hidden" id="idstamp" name="idstamp" value="CV3PY+k/SkW39SctDep5xw==" > <input type="hidden" id="encryptedPassword" 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