How should your name and credentials read on your certificate?

This bio will be displayed on a powerpoint slide. Please provide bulletpoints with the information below:
 

• Year you joined ACMT
• Name of Schools Attended (Residency, Fellowship, etc.)
• Clinical Title, Name, Location
• Academic Title, Name, Location
• Additional Titles, Role(s), Location
• Any other projects, ACMT-related tasks you'd like to mention

Please attach your CV here or email it after submission to membership@acmt.net with the subject "FACMT Application" and your name.

Please indicate which 2 or more of the numbered categories you will be submitting for consideration:

Are you practicing toxicology in a medical setting, either academic or private?

Are you practicing in an industrial or government setting?

Please list all medical toxicology practice locations, including dates and percentage of professional activities that this entailed. The clinical practice of medical toxicology as a minimum of 50% of professional activities for a minimum of 4 years is required to meet this criterion.

(If different from practice location) Please list all medical toxicology consultation locations, including dates and the percentage of professional activities that these consultations entailed. The practice of medical toxicology consultations as a minimum of 50% of professional activities for a minimum of 4 years is required to meet this criterion.

With regards to industrial or governmental toxicology service, please list job title/position, the location of the practice, the dates and percentage of professional activities that these positions entailed. Service to industry or government in the field of toxicology of pharmaceuticals as a minimum of 50% of professional activities for a minimum of 4 years is required to meet this criterion.

Publications used to satisfy formal teaching should NOT be used to satisfy research.

Please list all medical toxicology teaching sites (hospital, university, etc.), associated academic appointment (if applicable) and dates of formal teaching. Formal teaching of medical toxicology to health care professionals or trainees for a minimum of 4 years is required to meet this criterion.

Please list a minimum of four (4) textbook chapters and/or medical journal publications, including case reports in the field of medical toxicology (in reference format in which you are author or co-author)

Please list all faculty appointments in medical toxicology teaching programs and applicable dates. A faculty appointment in a medical toxicology teaching program for a minimum of 4 years is required to meet this criterion.

(not counting abstracts, case reports, letter to the editor)

Please cite at least two (2) reports of original research in medical toxicology of an investigatory nature that have been peer reviewed in which you are the lead author, not including case reports, abstracts or letters to the editor.

Please cite at least four (4) reports of original research in medical toxicology of an investigatory nature that have been peer reviewed in which you are a contributing author, not including case reports, abstracts or letters to the editor.

If yes, please list dates and the name of the organization: 

If yes, please add the dates and name of the organization:

Please list the regional poison center, your role (director, medical director, assistant director, assistant medical director) and the dates that you filled that role. Service as a Director/Medical Director or Assistant Director/Assistant Medical Director of a poison center for a minimum of 4 years is required to meet this criterion.

Please list your affiliation as a member of a governmental or public committee addressing medical toxicology issues, your position and dates of involvement. The minimum duration of this affiliation required to meet this criterion is 4 years.

Please list your affiliation as a member of a governmental or public committee addressing medical toxicology issues, your position and dates of involvement. The minimum duration of this affiliation required to meet this criterion is 4 years.

Please list your affiliation in a public service organization related to medical toxicology, your role (director, chairman or other leadership) and dates of involvement. The minimum duration of service in a leadership role (Chairman, Director, or other) required to meet this criterion is 4 years.

Please list any board affiliation you may have (Board of Directors of ACMT), your position on the board and your dates of service. The minimum duration of ACMT Board of Director membership required to meet this criterion is 3 years.

Please describe your service and involvement with the American College of Medical Toxicology. Include details such as committee memberships, leadership roles, meeting or pre meeting organization, participation on organizing committees, presentations at ACMT meetings excluding posters, and any authorship of ACMT Position Statements or White Papers.

Be sure to include your role(s), dates of service, and a brief description of your contributions. A minimum of four years of ACMT committee membership is required to meet this criterion.

Identify two current full, international, or affiliate members of ACMT (email address and telephone) from whom you will procure recommendations.

Letters should address specific categories pertinent to your application. Letters may be emailed to membership@acmt.net.

Please include their name and email address so that we may follow up with them:

By checking the following box, I certify that all information contained within this application is accurate to the best of my knowledge, and I have satisfied the eligibility criteria. You must check this to certify your completed application.