PRIMARY CLIENT REGISTRATION
Date: 25 September 2017
Authenticated User: none,     [NewClient]

Thank you very much for your interest in registering as a Client Site with CLASS - Clinical Ligand Assay Service Satellite, part of the University of Michigan, School of Public Health, Department of Epidemiology. We are committed to providing the scientific community with the best in ligand assay, collection kit development, assay development, sample repository, and results reporting services.

A completed Site Information Sheet is required for your site to be entered in the CLASS Client Site Database.  Please provide all data applicable to your site in the appropriate spaces below.  At the end of the form, click the "Submit Form" button.  You will receive a confirmation message from us shortly. However, YOUR ACCOUNT WILL NOT BE USEABLE UNTIL ACTIVATED BY CLASS. Thisusually takes about 24 hours or less.

We have made every effort to make all aspects of the registration process as easy, secure, and reliable as possible. However, if you need help or have questions concerning the features available to client sites on this section, please click on one of our name links below for assistance.  Thank You!

Dr. Daniel McConnell, Director of CLASS Labs
Mark Patton Davis, Manager of Information Technologies
Kim Gonzalez, Laboratory Manager

1.0 CLIENT PROJECT (Select the project or study associated with this registration)
Project/Study:

2.A SITE NAME AND ADDRESS (For correspondence)
Site Name:
Address (1):
Address (2):
City: Zip/PC:

2.B SITE ADDRESS (For shipping)
Same as above:   (or uncheck box to enter an address)
Address (1):
Address (2):
City: Zip/PC:

3.A CONTACT PERSON (Primary)
Honorific: Mr.     Mrs.     Miss     Ms.     Dr.     None    
Name:    
Title:
Phone#: Fax#:
E-mail:

3.B CONTACT PERSON (Secondary)
None Available:   (or uncheck box to enter contact information)
Honorific: Mr.     Mrs.     Miss     Ms.     Dr.     None    
Name:    
Title:
Phone#: Fax#:
E-mail:

4.0 SECURITY (Defining your user account)
Using the following three input fields, you will define the username and password that will give you access to the CLASS web site. Both the username and passwords are composed of 6 to 16 characters/numbers from the set [a - z, A - Z, and 0 - 9]. Activation of your account will usually be accomplished within 24 hours. You will be notified by e-mail when your account is available for use.
Select a UserName (The username you will use to log onto this system)
Select a Password (6 to 16 characters/numbers, case sensitive)
Re-enter Password (Please re-enter to confirm your password)

5.0 APPLICANT'S CERTIFICATION
The undersigned hereby certifies that the foregoing information is a true and correct statement of the facts and agrees to abide by the laws of the State of Michigan and the rules and regulations of the University of Michigan.
   Person Authorized to Sign this Application: 

Title:   Date: