2010 International Affiliate Annual Dues
Dues are based on World Bank resident country income group category
HI and UMI resident country: $260
HI/UMI with only an online subscription to the American Journal of Geriatric Psychiatry: $225
LMI Resident Country: $90
LI Resident Country: $40

AAGP dues are not deductible as a charitable contribution for tax purposes. However, they may be deductible as a business expense subject to restrictions imposed as a result of association lobbying activities. AAGP estimates the nondeductible portion of your dues to be 29%.

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?	Yes No  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?	Yes No
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?	AAGP Member Colleague AAGP Mailing AAGP Website Other (please specify)
Have you ever attended the AAGP Annual Meeting?	Yes No
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	VISA MasterCard
Card Number
Expiration Date	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2010 2011 2012 2013 2014 2015 2016 2017
Amount	2010 U.S. and Canada Dues $250 (Affiliate) 2010 International Affiliate Dues $260 (HI/UMI Resident Country) $225 (HI/UMI - online only subscription to AJGP) $90 (LMI Resident Country) $40 (LI Resident Country)
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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