Application form for Supported Medical Membership of the IAC

For this form you will require:

Information about your medical training and experience in the field of cytology
A copy of your medical degree
A copy of your specialist diploma
A short copy of your CV indicating your training and experience in cytopathology. In English.
A small photograph for internal purposes only.
Applications also require at least one sponsor who is an IAC member.

The names of accepted members are added to the IAC list of new members and the list of active members In the IAC members area.

Personal Information

Hidden

Date

Your Given Name*

Given Name

Your Family Name*

Family Name

Your date of birth*

Please enter your date of birth beginning day/month/year

Your email*

Please enter your contact email

Phone*

Where shall we send your journal and IAC postal correspondence?

Please enter a full postal address. If your work address please include the department.

Please do not try to fit your address on one line.

Address Line 1*

Address Line 2

Address Line 3

City / Town*

Postal Code

(If required) State / Region /Province

Not every address requires a state

Country*

Sponsor

You will need a Member or Fellow to sponsor your application.

Sponsor*

I have a sponsor

I am unable to find a sponsor

Please explain your situation and why you do not know an Academy member who could sponsor you.*

Sponsor Name*

Please enter the name of your sponsor.

Sponsor email*

Please enter your sponsor contact email. When you submit this form an email will be sent automatically to your sponsor asking them to confirm.

Your professional information

Your current position*

Current Employer*

Name of employer/ Your name if self-employed

Your work address, if Hospital or Medical Center include name of institute and department*

Your medical degree and training

Medical Degree (Year)*

Name and address of School / University / Institute*

Where do you achieve your medical degree?

Specialist Training

Where did you receive your specialist training?*

University/Hospital/Institute. Name and address.

I am a certifiied specialist in my country of residence.*

Yes

No

I passed my specialist examination in (subject):*

Year*

The qualification situation in my country*

Please describe the qualifications you gained that are necessary for you to practice cytopathology in your country of residence.

Required documents

Please upload a copy of your specialist certificate*

Accepted file types: pdf, jpg, png, Max. file size: 146 MB.

Your CV should clearly indicate your training and experience in cytopathology or clinical cytology

Does your CV clearly indicate where and when you gained your expereince and training in cytology?*

At least one year full time training or experience in cytopathology is required.

Yes, my training and experience in cytology is recorded in my CV

No, there is no mention of cytology training in my CV

Please indicate where and when you gained your experience and training in all aspects of cytopathology

Please upload a copy of your CV*

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 146 MB.

Publications (last four years only)

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 146 MB.

Please upload a passport sized photograph (Headshot)*

Please DO NOT submit a copy of your passport. The picture will not be published and is for internal reference only.

Accepted file types: jpg, gif, pnd, pdf, Max. file size: 146 MB.

Phone

This field is for validation purposes and should be left unchanged.