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ID and Password Application Form for Asia CML Study Alliance

Please fill out this application form to obtain a user ID and password for Asia CML StudyAlliance (ACSA).
Your user ID and password will be emailed to you after you have completed the form.

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First Name		Middle Name
Last Name		Title
Name of Principal Investigator
Organization
Department
Street address
City		State/Province
Country		Zip Code
Work phone		Fax
E-mail

I agree to adhere to all Asia CML Study Alliance (ACSA) policies governing Asia CMLRegistry (ACR) use.
I will strictly maintain the confidentiality of my ACR ID and passwordand will not share them with anyone.
I understand that failure to comply with these policies will result in the immediate termination of my account.