The Voice of Academic Neurology's Leaders

Institutional Profile Form

All membership category positions listed below are covered by the AUPN annual dues and therefore are entitled to all AUPN benefits. This includes receiving the Saturday newsletters and access to all educational offerings.

If there is not an individual in a specific role, please leave blank.

Please contact neuro@aupn.org with questions.

Institution Contact Information:

Institution Name *
Institution Address
City
State
Zip
Phone

Neurology Department Chair (billing contact)

Chair Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)

Residency Program Director

Program Director Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)

Clerkship Director

Clerkship Director Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)

Child Neurology Residency Program Director

Child Neurology Program Director Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)

Research Program Director

Research Program Director Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)

VA Director

VA Director Name (first, last)
Suffix (MD, PhD, etc.)
Nickname (if applicable)
Email
Phone (if different than above)





Fields marked with * are required.

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