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The Research Affiliates Program

Gold Level Membership registration form and confidentiality agreement

*Designates required information

*Email:
Salutation:	"Dr. Ms. Mr. Prof.
*Name:
Organization:
Dept/Mail stop:
Address:
Address:
City:
State/Province:
Zip/Postal code:
Country:
Phone:
Fax:
*Primary contact person:

NOTE: The Primary contact person will receive all written communications from The Jackson Laboratory that are relevant to the Research Affiliates Program. Additionally, the Primary contact person must authorize use of the program services by any other company personnel. Only authorized users will be given access to the services provided by this program.

User authorization
I authorize the following people to use the services provided by membership in the Research Affiliates Program at The Jackson Laboratory:

Name:
Email:
Name:
Email:
Name:
Email:
Name:
Email:
If you would like all employees authorized to use the service, please check here:
Form completed by:
Date:	(mm/dd/yy)

Please review our Confidentiality Agreement

Gold Membership gives you facilitated access, including:

• All benefits for subscription-level members
• 1 Free on-site seminar
• Facilitated scientific interactions with The Jackson Laboratory Research and Resource scientists
• Complimentary registrations to attend The Jackson Laboratory’s Courses and Conferences
• Complimentary registrations for Discovery Strategies, a conference designed specifically for topics of interest to scientists in biomedical industry

The first ten (10) hours our staff scientists spend on Facilitated Interactions will be covered by The Jackson Laboratory Research Affiliates Program.  All travel, lodging, and out-of-pocket expenses incurred by Jackson personnel as a result of any consultation will be paid for by your organization. All travel, lodging and out-of-pocket expenses incurred by your personnel in conjunction with this program will be paid for by your organization.

For pricing information, please contact:

MaryEllen Joseph
The Jackson Laboratory
610 Main Street
Bar Harbor, ME 04609
Tel: (207) 288-6188
Fax: (207) 288-6152
Email: maryellen.joseph@jax.org