NLA Application for Associate Membership

PLEASE READ BELOW, YOUR APPLICATION WILL BE IMMEDIATELY REJECTED IF:

Personal Information
How did you hear about the NLA?
Courtesy Title:
First Name:
Middle Name:
Last Name:
Suffix: (Jr., Sr., etc.
Degree: Help
Job Title: Help
Date of Birth: Gender:
Email Address: Help
Web Account Information:
The following two fields will establish a web account for you, allowing you to access members-only features on our website. You can use an email address as your username; but be aware that your username will displayed publicly with all your activity on the website and so your email will essentially be public information. We recommend against this.
Username: Help
Password: Help
Communications:
By applying for membership in the NLA, you are agreeing that we may communicate with you INDIVIDUALLY by email, fax or land mail for purposes directly related to your membership such as purchase receipts, membership information and other purposes related to the maintenance of your account. Additionally, by default, you will be subscribed to our electronic communications such as newsletters, meeting announcements and educational opportunities which will be sent most often via email and on rare occasions may also be sent by facsimile. If you do not wish to receive these communications, you may uncheck the boxes below. You may change these preferences at any time once your membership has been activated. We hope you'll stay subscribed. We promise to keep our communications concise, relevant and worth reading.

I authorize the NLA to send me facsimile communications related to my membership and the association ( 3-4x per year )

I authorize the NLA to send me email communications related to my membership and the association ( 1-3x per week, depending on options selected )
Contact Information
Send Mail To:
Office Address: Help
Country:
Organization:
Street Line 1:
Street Line 2:
City:
State or Province: Postal Code:
Phone: Fax:
Home Address:
Country:
Street Line 1:
Street Line 2:
City:
State or Province: Postal Code:
Phone: Fax:
About Your Practice
Category: (Other - Please Specify):
Type of Practice: (Other - Please Specify):
Ethnicity: Help
Professional, Practice, or Organization Website (if applicable):
Please explain in a few words how you are involved in the treatment, research or education related to lipid disorders:
Education
College: Degree: Year: Format: YYYY (eg 1983)
Graduate: Help Degree: Year: Format: YYYY (eg 1983)
Medical: Help Degree: Year: Format: YYYY (eg 1983)
Internship/Residency:
Fellowship: Year: Format: YYYY (eg 1983)
Postgraduate: Degree: Year: Format: YYYY (eg 1983)
Verification of Trainee Status

Documentation is Required: A letter from your program director or the school registrar validating your enrollment in a qualifying program of study, and including the expected completion year, must accompany the application.

Attach the Letter:

*We allow only the following document types: '.doc', '.pdf', '.jpg', '.gif', '.png','.bmp', '.docx' .
*The maximum size of your file is 200 KB.


Certifications and Licensure
License State: License Number: Year Issued:
Board 1: Year Obtained:
Board 2: Year Obtained:
Board 3: Year Obtained:
Present Medical School/Hospital Affiliations/Appointments: