AAGP - Join - Affiliate Application

AAGP Affiliate Membership Application for Non-Psychiatrists

The American Association for Geriatric Psychiatry (AAGP) is pleased to announce the sixth year of the AAGP Affiliate program for non-psychiatrists. The AAGP membership committee will review applications of persons interested in becoming Affiliates to determine those individuals who meet the criteria, and will forward their names to the Board of Directors to be voted upon, after which you will be contacted.

Eligibility

1. The applicant must have an advanced degree (masters level or higher); and
2. The applicant must meet ONE OR MORE of the following criteria:

2a. have an active research grant (as principal or co-investigator) in an area related to geriatric mental health;
2b. have attended the AAGP/NIMH Summer Research Institute;
2c. spend at least 50% of his or her time in clinical practice (e.g., psychology, neuropsychology, internal or family medicine, neurology, nursing, or another discipline), teaching, or administration devoted to geriatrics.

Rights and Benefits
Affiliates receive all standard member benefits (e.g., subscriptions, member discounts) and may:

1. as determined by the Board, serve on committees in a non-chair capacity;
2. attend AAGP open Board Meetings; and
3. participate for a reduced annual fee (e.g., $185 vs. $245 for Full Members).

Please note: AAGP Affiliates will not be members of the association as legally defined in its bylaws. At this time, Affiliates may not sit on the board, chair committees, sit on the Executive or Nominations Committee (Public Policy Committee--TBD), vote for board members or on referenda, or participate in AAGP governance. Affiliates may serve on some AAGP committees and elect their own leader to communicate with the AAGP Board of Directors.

2008 Annual Dues (Half-year dues: July 1 - Dec. 31, 2008)
Affiliate Member: $92.50

Membership is for July 1 - December 31, 2008.

If you are applying for affiliate membership in conjunction with your AAGP annual meeting registration, do NOT submit your payment here. Payment information should be included ONLY on the meeting registration form. Your membership dues are included in your annual meeting registration by checking the appropriate category.

Required Fields marked with an asterisk (*)

GENERAL INFORMATION
* First Name, Middle Initial
* Last Name
* Degree(s)
Institution/Company/Organization
* I prefer for you to send materials to my	Residence Office
* Preferred Mailing Address
* City
* State
* Zip
Country
* Phone
* Fax
AAGP needs your written consent to fax any AAGP product or service correspondence to you. If you agree to this consent, AAGP will not sell your fax number to third parties. Please note that you can revoke this consent at any time by alerting AAGP in writing.
I provide consent to AAGP to fax me about AAGP/GMHF products and services at the fax number above

* Email
* My second address is a(n)	Residence Office
Second Address
City
State
Zip
Phone
If an AAGP member referred you to AAGP, please list his/her name:


EDUCATIONAL BACKGROUND
Degree
Area of Study
Year
Institution
City, State	,
Country
Degree
Area of Study
Year
Institution
City, State	,
Country
Degree
Area of Study
Year
Institution
City, State	,
Country
Post graduate/Fellowship training	Year:
Post graduate/Fellowship training	Year:
Board or other certifications	Year(s):
Are you a graduate of the AAGP/NIMH Summer Research Institute?	Year(s):
PROFESSIONAL BACKGROUND
Professional Licence(s) held
Professional Membership(s) held
Current Positions
Job Title
Institution/Organization/Company
Job Title
Institution/Organization/Company
Please describe how your work relates to mental health and aging, including the percentage of your work week dedicated to this function.
Do you have any current research grant(s) related to geriatric psychiatry for which you are a principal or co-investigator?
Grant Title
Funding Source
Principal Investigator(s)
Grant Title
Funding Source
Principal Investigator(s)
REFERENCES
Please list the names and phone numbers of two professional references that AAGP may contact who are familiar with your work related to geriatric mental health. AAGP members are preferred.
Name
Degree
Phone Number
Title
Affiliation
Name
Degree
Phone Number
Title
Affiliation
MEMBERSHIP INFORMATION
How did you initially hear about AAGP?
Have you ever attended the AAGP Annual Meeting?
Year(s)
Check here if you agree with the following statement: I affirm that all information provided is correct to the best of my knowledge.
Any other information we need to know that did not fit on the application? characters left
PAYMENT OF ANNUAL DUES
Please use this secure form to provide us with credit card information for payment of your annual dues.
Name on Card
Billing Address	Copy From Above
Billing City, State, ZIP	,
Billing Country
Type of Card
Card Number
Expiration Date
Amount	$92.50 (July-December)
If you are applying for affiliate membership in conjunction with your AAGP annual meeting registration, do NOT submit your payment here. Payment information should be included ONLY on the meeting registration form. Your membership dues are included in your annual meeting registration by checking the appropriate category.

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