National Academy of Neuropsychology

2023 Fellow Application

Thank you for your interest in applying for Fellow status. In addition to the questions below, you will need three letters of support to upload here in this application. It is recommended that you wait until you have your three letters of support before completing and submitting the application below. Once you submit, you are not able to edit your responses and would have to resubmit your application in its entirety.

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* Name:

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* Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

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* Member of NAN since:

Educational History

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* Degree:

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* Date of Degree:

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* Degree-Granting Institution:

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* Post-Doctoral Training:

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* Dates of Post-Doctoral Training

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* Institution & Department of Post-Doc:

Professional History

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* Current Position:

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* Professional Honors/Awards/Recognition:

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* Please upload your current curriculum vitae.

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Fellow status in NAN is awarded to an individual who has made a significant contribution in one or more of the following areas: scientific and scholarly publications, teaching, volunteering in NAN or other advocacy activities, significant activities contributing to the advancement of the profession of neuropsychology, and clinical excellence. Please list your contributions below so we may evaluate your contributions in all areas.

Please List Outstanding Contributions:

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* Scientific:

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* Number of neuropsychology related peer-reviewed publications:

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* Number of neuropsychology related books and/or book chapters:

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* Teaching/Supervision:

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* Clinical Practice:

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* Professional Leadership/Contributions to the Advancement of the Profession:

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* Service to NAN/Advocacy Efforts:

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* Please include a list of references (in APA format) of what you feel are your ten most important neuropsychology publications.

Sponsors:

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* Sponsor 1

Name

Email Address

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* Please upload letter of support from Sponsor 1.

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* Sponsor 2

Name

Email Address

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* Please upload letter of support from Sponsor 2.

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* Sponsor 3

Name

Email Address

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* Please upload letter of support from Sponsor 3.

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