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Resources Personal Data Form

* Nominating IARLD Fellow/Member's Name
* NAME:
DATE:
ADDRESS:
* PROFESSIONAL:
HOME:
TELEPHONE: (Please include country and area code numbers.)
OFFICE:
HOME:
FAX:
* EMAIL:
DISCIPLINE:
ACADEMIC OR PROFESSIONAL TITLE:
ACADEMIC DEGREES: (Please spell out completely, i.e., Doctor of Philosophy in Psychology, Doctor of Medicine, etc):
EXACT MANNER IN WHICH YOUR MAIL SHOULD BE ADDRESSED (Prof., Dr., Mr., Mrs., Ms., or other):
LIST BELOW 3 OF YOUR RESEARCH INTERESTS IN ORDER OF PRIORITY
1
2
3
LIST BELOW YOUR PUBLICATIONS IN THE LAST 3-5 YEARS AND SPECIAL HONORS, AWARDS, ELECTED POSITIONS, APPOINTMENTS, ETC. RECEIVED IN THE LAST 3-5 YEARS.
LANGUAGES SPOKEN AND READ:
Primary:
Secondary:
If you are elected to the Academy, can we include your name, E-mail address, and a synopsis of the information above in the next Newsletter welcoming new members? (Please feel free to attach another page.)
YES NO
Can we include your recent publications in a listing of IARLD members' publications?
YES NO
Can we include your information in the IARLD Directory?
YES NO
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