Membership Information
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Association of Clinical Scientists

On-Line Proposal of Candidate for Membership

Last Name:
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First Name:
 *
Work Address:
Address Line 2
City:
State (or Province):
Zip Code:
Country
Work Phone:
 *
Fax Number:
E-mail:
 *
Home Address:
Address Line 2:
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State (or Province):
Zip Code:
Country:
 Home Phone:
Fax Number:
E-mail:
   
Bithplace:
Birthdate
Country of Citizenship
Gender:



  Education  (Institution, Locations, Dates, Degrees)
 
  Postdoctoral Training (Institutions, Locations, Dates, Certification, Licensure)
 
  Past Positions (Institutions, Locations, Dates, Titles)
 
  Present Position (Institutions, Locations, Dates, Titles)
 
  Clinical and Scientific Expertise (Subspecialty, Clinical Focus, Research Emphais)
 
 
Membership Category:
Candidate's Signature:
Date:
Sponsor's Signature:
Date:
Curriculum vitae:
Bibliography:
 
(Please upload your c.v. and bibliography in PDF, word document file, text or jpeg) Do not exceed 1 megabyte total in size.
   
  The Sponsor nominates the candidate, who fulfills all the requirements for membership and subscribes to the goals and objectives of the Association of Clinical Scientists.
   
 
 

 

Association of Clinical Scientists
PO Box 1287 * Middlebury, VT 05753 * USA
Tel: (802) 462-2507 | Fax: (802) 462-2673 | E-mail: info@clinicalscience.org
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