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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.
Please indicate the percentage of time you spend in each of the following professional actitivies (total should not exceed 100 percent)
As a part of the CAG’s Diversity and Equity initiative, we are asking our members to complete the following demographic questions in order to help us identify segments to better understand and serve our membership. Please note this information is strictly confidential and used only for the CAG’s purposes only.
To be considered for CAG membership, this application must be seconded by a Regular CAG member in good standing. By providing the name of my Nominating Supporter on this application, I allow my application to be viewed by them.
Please submit at least one of the following files: for physicians, a copy of your license to practice, certificate, appointment letterfor 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 ATTACHEMENTS ARE PDF FILE EXTENSIONS ONLY.
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.
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.
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.