Name

First name

Title Mrs Miss Mr Doctor Professor Other

Position

Structure

Organization Academic Industrial Institutional Other

E-mail

Telephone

Address

Zipcode

City

Country

Imaging modalities involved Magnetic fields Nuclear medecine X-ray Optic Ultrasound Electrophysiology Other

Nature of application Scientific partnership Commercial partnership Other

Kind of study Single center Multi center

Number of subjects

Deadlines

Data management Local archiving Centralized archiving

Data processing By the plateform By yourself

Other field than imaging

Application field

Please attach a summary of your application and your project (non-confidential) and any useful document. Upload a file

I authorize FLI to send me information to this address

Send