Affiliate Membership Application Form - International Academy of Aviation and Space Medicine

Affiliate Application Form

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Full name(*)

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E-mail(*)

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Title(*)

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Phone number (including country code)

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Position(*)

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Organization(*)

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Address

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I hereby apply to the International Academy of Aviation and Space Medicine as:

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AFFILIATE

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Have you attended an Academy Congress?(*)

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Provide a brief statement to explain your interest in the Affiliate programme and your goals as an Affiliate of the Academy (eg what is your current role, your immediate and longer term career goals, your interest in having a mentor):(*)

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In further support of this application, the following enclosures are submitted (in English or French):

1. Evidence of qualification in medicine or in an allied science; (photocopies of Degrees and Diplomas)

2. A Curriculum Vitae (maximum 5 pages) including:
a) A description of previous and present professional activities - highlight activities in aviation or space medicine;
b) A list of personal publications if any - list separately, or highlight, any aviation or space medicine publications;
c) A statement of aviation activities, including personal flight experience;
d) A statement of membership and status in professional and aeronautical societies.

3. A recent photograph;

IMPORTANT: Accepted file types are PDF, JPG, JPEG, PNG.(*)

Please upload the documents.

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I subscribe fully to the objectives of the Academy.

Please check this box if you agree.

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I am exercising clearly established functions and activities in the field of Aviation, Space Medicine, or related sciences.

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I consent to my application being retained by the Academy and circulated to officers and post holders of the Academy in accordance with its privacy policy.

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I certify that information contained in any document pertaining to my Affiliate application is accurate, and that any copy of a document which is submitted is a true representation of the original.

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Affiliate Application Form

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