Applicant Information

Membership ID #:      

Title: 

Place of work: 

Mailing address: 

City:       State:       Zip:  

Is this address for business or home? Business    Home

Day phone:       Fax: 

E-mail: 

Applicant Qualifications

Duration of Membership. Applicant has been an Academy member for at least two years.

How long have you been a member of the Academy (number of years)?         

First-time Attendee. Applicant has not previously attended a national conference sponsored by the Academy of Correctional Health Professionals.

Have you ever attended a conference sponsored by the National Commission on Correctional Health Care or Academy of Correctional Health Professionals?   Choose one Yes No

Professional Enhancement. Applicant will benefit significantly from attendance at the Updates conference.

How will attending this conference benefit you professionally? (no more than 500 words)

is there anything else the committee should know as they consider your application?