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 check the box to confirm that you have held the FACMT designation for at least 10 years

Candidates for DFACMT must meet 1 of the 3 of the following criteria. (Please select 1 or more):

Please indicate which 3 or more of the numbered categories you will be submitting for consideration:

Have you served as a speaker at 3 or more ACMT National Conferences or ACMT Board Review Meetings? If so, please list the years and session titles.

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

Please cite at least ten 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.

Please list your affiliation as a board member of a governmental or public committee addressing medical toxicology issues, your position and dates of involvement.

Have you held a position of Medical Toxicology Section or Division Chief for at least 6 years? If yes, please expand upon the details and dates of your role: 

Have you held a leadership role in the hospital including serving on the Pharmaceutical and Therapeutics committee, patient safety committee, IRB, peer review (QI) committee? If yes, please list title, organization and dates:

Have you served as a Poison Center Medical Director or Assistant Medical Director for at least 8 years? Please list the regional poison center, your role (director, medical director, assistant director, assistant medical director) and the dates that you filled that role.

Have you served in Government or public committee role addressing medical toxicology for at least 6 years? 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 6 years is required to meet this criterion.

Please share significant volunteerism or significant other activities including position, organization, projects, and dates of engagement. If yes, please list title, organization, details, and dates:

Please share other activities or high honors that distinguish the physician as preeminent in the field of medical toxicology including position, organization, projects, and dates of engagement:

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.