NAAMA Scientific and Professional Data Bank Application

APPLICANTS - Physicians, Dentists, Pharmacists, Nurses, Scientists and Researchers, Public Health and Social Workers, Administrators, Allied Health Professionals, Students

Description

The information gathered will help NAAMA to identify scientific and professional talent and expertise in individuals who choose be engaged in future NAAMA sponsored activities.

Criteria

Members or would be members of NAAMA, who have the knowledge and the desire to participate are invited to submit detailed information, about their scientific and professional accomplishments, which will be entered in the database and updated periodically. This will consists mostly of references for published articles and abstracts, books or book chapters, ongoing grant-supported studies, scientific lectures and seminars held, as well as expertise claimed of professional or administrative nature.

Application Requirements

• Applicants must submit a completed application - all responses must be completed on this form
• Curriculum vitae (limited to two pages), may be attached or mailed to the office

Electronic format is preferable for the application submission. Otherwise, you may download the Data Bank Application and email it to naama@naama.com.

Personal Information: Please select one title:

Mr.	Mrs.	Ms.
M.D.	D.O.	O.D.
D.D.S.	D.C.	D.P.M.
Pharm.D.	R.N.

Name
Last Name
Street address
Address (cont.)
City
State
Zip Code
Country
Work Phone
Home Phone
Work Fax
Home Fax
E-mail
Education:
Medical/Dental/Other School Attended
Year Graduated
Specialty
Board Certified?
Subspecialty
Board Certified?

Briefly, please describe any responsibility you may have in each of the following fields
		Positions held	Duties
Academia
Professional
Other medical societies
Community
Other

Please list three topics you believe you would qualify as an “expert” in (most comfortable to lecture about):

Publications: Please list your 10 most recent published articles (indicate original work or review by checking O/R)

O	R	Journal	Title

Other publications:

Book or Chapter Title	Year Published

 

 

 

 

 

List any active research projects:

Topic	Funding	Time Frame

Abstracts

Title	Venue/Year

Membership status

Please identify your membership status in the following organizations (for information only):

NAAMA
AMA
State Medical Society	Please specify
National Specialty Society	Please specify

I agree that all infromation entered is accurate and correct and is submitted for NAAMA's use only

Name: