Membership Application

ACE Admissions Committee

1500 Sunday Drive, Suite 102

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 currently an ACE member . Yes No

I am an existing ACE member requesting promotion.

Race (optional):

Amer Indian/Native Amer/ Alaskan Native/First Nation

Asian/Asian American/Pacific Islander

Black/African American/African

Hispanic/Latino/Latin American

White/European/Middle Eastern

Other (specify) _____________

Areas of Research Expertise (check all that apply):

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

Preferred Address:

Street ___________________________________________________________ City    _____________________________

State/Province ______________________ Zip/Postal Code __________________ Country ___________________________

Daytime Telephone ____________________________             Fax ____________________________

Email Address ____________________________________________________

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) ______________________________________

Training (check only one):

_____ PhD in epidemiology

_____ Relevant doctorate and masters degree in epidemiology

_____ Relevant doctorate and 2 year supervised fellowship or postdoc in epidemiology

_____ Relevant doctorate and sustained experience in epidemiology

Training details (dates of degrees and fellowships, specializations, institutions relevant to "Training" specified above):

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Attach your curriculum vitae (and any supporting materials) to this application and mail to:

ACE Admissions Committee
1500 Sunday Drive, Suite 102
Raleigh, NC 27607

Questions? Contact:
Nancy Kreiger
416-971-9800 x1239
nancy.kreiger@cancercare.on.ca