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* 1. Name

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* 2. Email address

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* 3. Institution

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* 4. Which of the last three Annual Academies Collaborative meetings have you attended? (Select all that apply)

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* 5. Academy Title (if no Academy currently exists, type “none”)

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* 6. Year established (if no Academy currently exists, briefly describe  plans to initiate an Academy)

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* 7. Brief description of your Academy (e.g., mission/core purpose(s), membership, predominant activities, etc.; if none yet established, type “not applicable”):

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* 8. Your role (current or previous) in the Academy (e.g., formal responsibilities, title, experience; if working to establish an Academy, describe what you are doing or have done)

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* 9. Why are you interested in being a member of the AC Steering Committee?

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* 10. What are specific talents, knowledge, experiences that you can contribute to the AC Steering Committee and to its success in meeting its charge?

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* 11. Upload your CV here (PDF, DOC, and DOCX files only).

PDF, DOCX, DOC file types only.
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