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Polaris

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CompanyIRB Membership RosterMultiple Assurance # (if applicable): ___________ Effective Date of Roster: _____________Membership Status Name DegreesRepresentativeCapacity(Scientific/Nonscientific)RelationshipwithCompanyExperienceChairmanSecretaryPrimary Voting MemberPrimary Voting MemberPrimary Voting MemberPrimary Voting MemberPrimary Voting MemberAlternate Voting MemberAlternate Voting MemberAlternate Voting MemberAlternate Voting MemberAlternate Voting MemberNon-voting ConsultantNon-voting ConsultantNon-voting ConsultantIRB Member.doc© 2004 by CRC Press LLC

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