Applicant Details

Preferred Mailing Address

In accordance with federal regulations effective January 1, 2004, the CAG is required to keep confidential all personal information provided by its members (unless authorized otherwise), and to disclose how this information will be used.

Education Details

Education History

Undergraduate Education

Medical/Postgraduate Education

Training

Residency

Training

Biography Details

Professional/Training Activity

Please indicate the percentage of time you spend in each of the following professional actitivies (total should not exceed 100 percent)

Demographics

The CAG will report on summary demographic statistics only. Be assured, all individual responses will be kept confidential.

Credentials

Please submit at least one of the following files:
for Regular and Affiliate members, a copy of your license to practice, certificate, appointment letter
for Trainees and International Trainees, a letter from your program director (for residents and fellows) or your supervisor (for basic science trainees).

PLEASE ENSURE ALL ATTACHMENT FILE NAMES CONTAIN ONLY LETTERS and NUMBERS AND NO SPECIAL CHARACTERS

For security reasons, our system does NOT accept submissions that contain any special characters, which includes any and all Symbols, Accent Marks and Punctuation marks including: - !* # ; ? \ / : " < > | . + & ^ % `

PLEASE ALSO ENSURE THAT ALL ATTACHMENTS ARE PDF FILE EXTENSIONS ONLY.

Privacy Policy

As a member of the CAG, we ask that you provide us with certain personal identifiable information that can be used to contact or identify you (personal Data). Personal identifiable information may include but is not limited to: Email, First Name, Last Name

We may use your personal data to contact you with monthly newsletters, marketing promotional material, conference material, scientific sessions and other information that may be of interest to you. This information will not be used for any other purpose other than the above by the CAG.

You may opt out of receiving any of these communications from us by following the unsubscribe link or the instructions provided in such email sent. 

Terms and Conditions

I certify the CAG to use my personal data to send me newsletters, marketing promotional material, conference material, scientific sessions, and other information that may be of interest to me. I understand I can unsubscribe anytime. I authorize that the above information and document(s) provided in this CAG Membership Application Form is true and accurate.

Electronic Signature

By checking this box and typing my name, I certify that I am the person accessing this webpage, submitting this form, and that all information on this form is true and correct.  I also agree that the checkbox and my name typed below are to be used as my electronic signature.