Institutional Profile Form | Association for University Professors of Neurology

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 Mailing Address
City
State
Zip
Phone

Neurology Department Chair

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 Chief

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

Vice Chair
One Vice Chair is allowed to serve as a member of AUPN. Please enter the Admin Vice Chair or a Vice Chair of the Department Chair's choosing.

Please note: Program Directors who are also Vice Chairs should be listed in the Program Director role and another individual should be identified for the Vice Chair Position.

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



Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

1935 County Road B2, W Ste 165 | Roseville, MN 55113 | 952-545-6724 | neuro@aupn.org
© 2023 Association of University Professors of Neurology. All rights reserved. Articles of Incorporation | Terms of Use
 
 


Reset password