Membership Registration

Application Information Form

Name of Applicant
Date of Birth

Place of Birth
Address

City

State

Zipcode

Office Phone

Fax

Email Address
1. Place of Employment
  
  Pharmaceutical Firm
  
  Government
  
  University
  
  Others (Please identify)
2. Choose only ONE of the following subgroups that best represents your interests
  
  Basic Research
  
  Clinical Research
1. Have you ever been convicted of, or pled guilty to, a felony or misdemeanor or been denied admission to or suspended or expelled from any professional organization?
  
  Yes
  
  No
2. Are there any outstanding judgements, lawsuits, bankruptcy or receivership actions pending against you, or any other form of material challenge to your character, personal integrity or business reputation?
  
  Yes
  
  No
3. Are you, or have you ever been, the subject of a malpractice, professional practice or ethics proceeding or investigation involving you or your professional work or ethical behavior?
  
  Yes
  
  No
4. If you answer Yes to any of 5A, 5B, or 5C, please explaing the situation below.
Upload your up-to-date Curriculum Vitae, which includes at least
1. Name
2. Academic Background (list schools, dates, and degrees)
3. Professional Experience
4. Professional Society Memberships
5. Government and other research support. Be specific and complete regarding amount, duration, project title, and name of Principal Investigator
6. Your published scientific reports in refereed journals. When listing the published scientific reports, the applicant needs to insure that in all of the material cited the order of authorship is the same as in the published material.
7. Your published scientific books and other published scientific abstracts, letters, book reviews, etc.
Upload your Applicant's Statement. Starting a new page, and with your name at the top, briefly describe your current major research theme(s) and/or relevant professional responsibilities. Major relevant contributions should be included with a description of their overall significance and importance to the Mission of the ICGP. A brief statement of future directions also needs to be included. The Applicant's Statement should be no more than 300-500 words.
Upload your References. The names, titles, and coordinates of 2 to 4 individuals who can write knowledgeably about your interest and involvement in geriatric psychoneuropharm-acology.
I certify that all of the above information is correct. Submitting this form serves as your signature on this form.

Membership Registration

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