Clinical Trial and Research Study Request Form

Requestor Information

Name:

Company: (Optional)

Address Line 1:

Address Line 2: (Optional)

City:

State or Province:

US and Canada:

Other:

Zip or Postal Code:

Country:

Email Address: (Your email address will not be released to any third party marketer)

Telephone: (Optional)

Is billing info the same as above?

Yes No

Name:

Company: (Optional)

Address Line 1:

Address Line 2: (Optional)

City:

State or Province:

US and Canada:

Other:

Zip or Postal Code:

Country:

Email Address: (Your email address will not be released to any third party marketer)

Telephone: (Optional)

Guilford Press Title Information

Book Title:

Author/Editor(s):

ISBN:

Year of Publication:

Page Numbers:

Scale or Assessment Name:

How Guilford Material will be Used

Protocol/Trial ID:

Phase:

Location:

Languages:

Number of Sites:

Number of Subjects:

TOTAL Administrations:

Duration of Study: from: to:

Method of Distribution: (Print, electronic, or other)

Anticipated Attendance / # Copies:

Number of Facilitators, Administrators, & Project Leads:

Format/Media requested (fill out all that apply)

(Optional)

Print only (quantity):

Electronic: Yes No

Details for Electronic Administration:

Other Comment