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Medidata Services Partner Application Form

Thank you for your interest in becoming a Services Partner in the Medidata Partner Program.

Because we recognize the value of our Services Partners, we are continuously striving to improve these relationships. These efforts have lead to the development of web-based materials, forms and eLearnings to make the program available in a way that is more flexible, on-demand and of lower cost for partners.

Please fill out the brief form below to begin the application process. An authorized representative from your organization will need to accept the terms and conditions at the end of the form.

1. First Name:

2. Last Name:

3. Company:

4. Company Website:

5. Country:

6. Your Email:

7. Your Phone (including country code):

9. Your Functional Area:

10. How many employees, including contractors, are in your organization?

11. Which geographic area drives your organization's revenue? (Please select all that apply)

Asia Pacific (APAC)
Europe, Middle East, Africa (EMEA)
Latin America
North America

12. Please indicate the market segment(s) you serve:

13. What is your organization's annual gross revenue?

14. How many studies do you start annually that would be suitable for paper?

15. How many electronic data capture (EDC) based studies do you start annually in each clinical phase?

Phase I
Phase II / III
Post-Approval

16. Please specify any partnerships you have with other EDC technology providers.

17. What are your organization's strengths that differentiate it from other competitors in your market segment? What helps you win business?

18. Please indicate your organization's expertise within therapeutic areas:

19. Please identify which types of services your organization provides (select all that apply):

20. Medidata delivers a cloud-based platform of innovative tools, data-driven metrics and system interoperability, all designed to optimize clinical trials from concept to conclusion. Please identify the Medidata Clinical Cloud applications that interest your organization at this time:

Study & Protocol Design
Trial Planning & Budgeting
Trial Management
Randomization & Trial Supply Management System
Electronic Data Capture & Clinical Data Management (EDC/CDM)
Monitoring
Safety Data Capture
Medical Coding

21. How many employees do you expect would participate in Medidata training as part of the partner accreditation process?

22. By submitting this application form, the Parties agree to be bound by the following confidentiality terms. Any and all information contained in this Medidata Services Partner Application Form ("Application Form") and exchanged by the parties through the selection process is proprietary and confidential to the disclosing party ("Confidential Information"). The information contained in this Application Form may be used solely in connection with the evaluation of the Medidata Partner Program.

To the extent a nondisclosure agreement (or other agreement with terms on confidentiality) protecting Confidential information is in effect between the parties, the information contained in this document and exchanged by both parties through the selection process shall be held confidentially in accordance with the terms of that agreement. If no agreement protecting the parties' Confidential Information is in effect between the parties, both parties agrees to (a) keep the Confidential Information in strict confidence and not to disclose it to any third party without the other parties prior written consent and (b) the parties internal disclosure of the Confidential Information shall be only to those employees, contractors or agents having a need to know such information in connection with the evaluation of the selection process and only insofar as such persons are bound by a nondisclosure agreement consistent with the foregoing. Neither party will acquire any intellectual property rights in the other parties property under the Application From and or through the selection process.

*This question is required.

I agree to the terms and conditions

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