Membership Application

Date of application (mo/day/yr ):________________________

Last Name:                                                                    First Name:                                                              Initials: _______   

Date of Birth (optional) (mo/day/yr): ___________________________                        Sex (optional): Male   Female

Please indicate your membership request:

I am not currently an ACE member
I am an ACE member requesting promotion
I am a former ACE member requesting re-activation.

Race and Ethnicity: (Mark one or more)
http://www.whitehouse.gov/omb/fedreg/ombdir15.html

American Indian or Alaska Native (person with origins in any of the original peoples of North and South America [including Central America], and who maintains tribal affiliation or community attachment)

Asian (person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (person having origins in any of the black racial groups of Africa)

Hispanic or Latino (person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race)

Native Hawaiian or Other Pacific Islander (person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
White  (person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Other (specify) _____________

Areas of Research Expertise (check all that apply):

Behavorial	Environmental	Hospital	Radiological
Cancer	Epi Methods	Infectious	Reproductiv
Cardiovascular	Eye	Injury	Respiratory
Chronic Disease	General	Molecular	Serology
Clinical	Genetics	Neurology	Tropical Disease
Dental	Geriatric	Occupational	Veterinary
Diabetes	Health Services	Perinatal	Other (specify)________
Drug	Health Policy	Psychosocial

Preferred Address:

Street ___________________________________________________________

City _____________________________ State/Province ______________________ Zip/Postal Code __________________

Country ___________________________

Current Employment:

Position/Title __________________________________           Employer __________________________________________

Retired/Emeritus	State, Local government
University/Medical School/School of Public Health	Private research firm
Industry	Independent consultant
Federal government	Other (specify) ______________________________________

* Have you considered  applying for Emeritus status with ACE

Training (check only one):

Doctorate* in epidemiology  (year degree earned YYYY)
Doctorate* in a field related to epidemiology**, with specific formal training in epidemiology of at least 1 year duration*    (year degree earned YYYY)
Doctorate* in a field related to epidemiology** with 2 years of supervised and structured experience in the practice of epidemiology  (year degree earned  YYYY)
 Doctorate* in a field related to epidemiology** and sustained experience in epidemiology    (year degree earned  YYYY)
 Masters’ degree* in epidemiology and 5-7 years professional employment**    (year degree earned  YYYY)
*Or equivalent degree
**For examples, please refer to the Admissions page of the ACE website.

Training details pertinent to your work as an epidemiologist (dates of other degrees and fellowships, specializations, institutions relevant to "Training" specified above):

 ________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

If you are requesting a new membership, please complete the following section:

How did you hear about ACE?
Annual meeting materials
Contacted by current ACE member
The Chair of your department or Dean of your medical school
Flyers or posters at your school or institution
Visits by ACE members to your school or institution
While attending annual meetings of Society for Epidemiologic Research or American Public Health Association or at the EPI Congress
Direct email/letter/phone call from ACE representative
Epidemic Intelligence Service program at the Centers for Disease Control and Prevention
Council of State and Territorial Epidemiologist colleagues
National Institutes of Health epidemiologists listserv