Affiliate Fellow

Requirements

(Must meet either criterion 1 or 2 and must meet both 3 and 4)

Applicant has attended or completed an ADA accredited Prosthodontic Residency and/or Maxillofacial Prosthetics Fellowship in the US, but does not qualify for associate fellowship at this time.
Applicant has international training in dentistry, prosthodontics, or maxillofacial prosthetics or any of these levels of training in the US and who has an interest in maxillofacial prosthetics with no current desire to become a full fellow; is simply interested in maxillofacial prosthetics.
Applicant is encouraged to be in good standing of the American Dental Association (ADA) or equivalent organization in the country in which they practice.
Applicant must submit a completed application 60 days in advance to the annual AAMP meeting or the AAMP interim board meeting. The application must be submitted to the fellowship chair which includes a mission statement on becoming an affiliate fellow, and after validation by the fellowship committee, the candidate will be voted on for approval by the AAMP Board of Directors.

For any questions, please contact the Executive Secretary of the AAMP.

Personal Information

Honorific

First Name

Middle Name/Initial

Last Name

Nickname

Significant Other First Name

E-mail

Date of Birth

Gender

Institution/University

Title/Position

Website

Please list all AAMP meetings and dates you have attended

Academic Training

	Institution	Degree	Year
Pre-Dental or Pre-Medical
Dental or Medical
Graduate

Post Graduate

List all short post-graduate courses in last five years (include course, institution, degree, year; one per line)

Specialty Board Certification

Certified?
Y N

Certification

Year

Fellow Program

Program

Year

Residential Program

Program

Year

Student Program

Program	Proposed Graduation Date
Institute	Department
Director	Director Email

Teaching or Hospital Appointments

List all teaching or hospital appointments (include institution, appointment, date; one per line)

Research Experience

List Research Experience (include project, grant source if applicable, and dates; one per line)

Please list papers, posters, essays, and workshops presented by you at dental or other professional meetings and the dates

List memberships in professional and scientific organizations (ADA, etc.) and offices held

Names of two Active Fellows of the Academy from whom the Secretary may obtain an endorsement

Name 1

Name 2

What is your purpose in wanting to join the Academy and in what capacity do you believe you can best serve the Academy?

Privacy Information

Show in member directories?
visible hidden

Who can view member details?
public members only administrators only

Do you consent to receive email communications from us, regarding your membership?
Y N

Yes, I agree to abide by the Constitution, By-Laws and other rulings of the Academy as well as such changes and amendments as may thereafter be properly adopted.

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