Membership Application

Date of application (mo/day/yr ):

Please indicate your membership request:

I am not currently an ACE member

I am an ACE member requesting promotion

I am a former ACE member requesting re-instatement

Race and Ethnicity

American Indian or Alaska Native (person with origins in any of the original peoples of North and South America [including Central America], and who maintains tribal affiliation or community attachment)

Asian (person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (person having origins in any of the black racial groups of Africa)

Hispanic or Latino (person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race)

Native Hawaiian or Other Pacific Islander (person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (person having origins in any of the original peoples of Europe, the Middle East, or North Africa)

Other (specify)

Areas of Research Expertise (Check all that apply)

 
Preferred Address:

Street:

City: State: Zip:

Country:

Daytime Phone: Fax:

Email Address:

Current Employment:

Position/Title:
Employer:

 
* Have you considered applying for Emeritus status with ACE?

Yes
No

Training:

Doctorate* in epidemiology

Doctorate* in a field related to epidemiology**, with specific formal training in epidemiology of at least 1 year duration*

Doctorate* in a field related to epidemiology** with 2 years of supervised and structured experience in the practice of epidemiology

Doctorate* in a field related to epidemiology** and sustained experience in epidemiology

Masters’ degree* in epidemiology and 5-7 years professional employment**

*   Or equivalent degree
**  For examples, please refer to the Admissions page of the ACE website.

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

How did you hear about ACE?

Please Select One Annual meeting materials Contacted by current ACE member The Chair of your department or Dean of your medical school Flyers or posters at your school or institution Visits by ACE members to your school or institution While attending annual meetings of Society for Epidemiologic Research or American Public Health Association or at the EPI Congress Direct email/letter/phone call from ACE representative Epidemic Intelligence Service program at the Centers for Disease Control and Prevention Council of State and Territorial Epidemiologist colleagues Other*

* OTHER:

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