Associate Member Nomination

Degree Type*
First Name*
Middle Initial
Last Name*
Suffix	-- Select a suffix -- II III IV Jr. Sr.
Phone*
Fax
Email*
Date of Birth
Gender	Male Female
Ethnicity	-- Select an ethnicity -- African-American Caucasian East Asian Hispanic Native American Other South Asian US Pacific Islander
If "other", specify
I understand that the information collected will not be identified with me personally. It may be used in statistical reports. I give my permission to use the information for statistical reporting.
Mailing Address 1*
Mailing Address 2
Mailing Address 3
City*
State*	-- Select a state -- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code*
Country*	United States Afghanistan Albania Algeria Andorra Angola Anguilla and Barbuda Antigua Argentina Armenia Aruba Ascension Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Colombia Comoros Congo Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jarvis Island Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Midway Islands Moldova Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palmyra Island Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Reunion Romania Russia Rwanda Saint Helena Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia and the South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Current Affiliation*
Place of employment*	-- Select a place -- Government Industry Other University
If "other", explain
Choose only ONE of the following subgroups that best represents your interests (you will be evaluated on this category of research)
Interest*	-- Select an interest -- Basic Research Clinical Research
Applied for associate membership before?*	YesNo
If yes, what years?
Applied for regular membership before?*	YesNo
If yes, what years?
Year most recent fellowship training was completed*
H-index*

Nominator 1: First Name*
Nominator 1: Last Name*
Nominator 1 Letter*
Nominator 2: First Name*
Nominator 2: Last Name*
Nominator 2 Letter*

Number of refereed journal papers*
Number of invited editorials and commentaries*
Number of book chapters*
Number of books*

Past Affiliations, Education & Awards*
Publications*
Grants and Patents*
ACNP Activities*
Role in Industry Projects
Attestations*

Published Paper #1*
Published Paper #2*

Upload in the same order in which they appear in your Publication form.
Abstract #1*
Abstract #2*
Abstract #3*
Abstract #4*
Abstract #5*
Abstract #6*
Abstract #7*
Abstract #8*
Abstract #9*
Abstract #10*
	Principles of Professional Conduct