Application form for Fellow of the AACT

Fellow of the AACT Application

This is the application for Designation as a Fellow of the American Academy of Clinical Toxicology. Deadline to submit application is June 1.

Step 1 of 3

Contact Information for Applicant
Applicant's Name*
First Last Credentials
Application Submission Date*
MM slash DD slash YYYY
Preferred Address for Contact*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Phone*
Nomination Letter
Nomination Letter:*
Enter the name and email address of the Fellow of AACT who is submitting the nomination letter on your behalf.
First Last Email Address
Nomination Letter*
Please upload your nomination letter for Fellow status from a current Fellow of AACT.
Max. file size: 128 MB.
Recommendation Letters
Applicants must submit two letters of recommendation from current Fellows of AACT with their application.
Letter of Recommendation #1:*
Name and email address of the Fellow of AACT who is submitting a recommendation letter on your behalf.
First Last Email
Letter of Recommendation #1*
Please upload your first recommendation letter for Fellow status from a current Fellow of AACT.
Max. file size: 128 MB.
Letter of Recommendation #2:*
Name and email address of the Fellow of AACT who is submitting a recommendation letter on your behalf.
First Last Email
Letter of Recommendation #2*
Please upload your second recommendation letter for Fellow status from a current Fellow of AACT.
Max. file size: 128 MB.
First Year of membership in AACT*
List all years of AACT membership (clearly indicating any gaps)
Upload your CV here*
Max. file size: 128 MB.
Upload your headshot here
Max. file size: 128 MB.

Service to AACT Core Functions
AACT Executive Committee of Officer*
Dates of Term*
AACT Board of Trustees Member*
Dates of Term*
AACT Committee Chair*
Includes ABAT President
List name(s) of Committee and Dates of Service*
AACT Committee Member*
Includes ABAT Board Member
List name(s) of Committee and Dates of Service*
List names of Committees and dates of service along with your contribution to each committee
AACT Section Chair*
Name of Section and dates of service*
AACT Section Member*
Dates of Section Membership and Contribution(s) to each Section*
Are you a Diplomate of ABAT?*
ABAT President*
Dates of Term*
ABAT Board Member*
Dates of Term(s)*
ABAT Committee Chair*
List name(s) of committees and dates of services*
ABAT Committee Member*
Names and dates of Committees and contribution to each*
NACCT Participation
AACT Pre-Meeting Symposium Chair or Organizer at NACCT*
Name and Date(s) of each symposium*
AACT Pre-Meeting Symposium Speaker*
Provide name and date(s) of each lecture or presentation*
NACCT Main Congress AACT Symposium (during NACCT) chair or organizer*
Provide name and date(s) of each symposium*
NACCT Main Congress AACT Symposium (during NACCT) Speaker*
Does not include platform sessions or lightening orals.
Provide Name and Date(s) of each lecture or presentation*
NACCT Abstract Committee Chair*
List each year served*
NACCT Abstract Reviewer*
List each year served*
NACCT Abstract(s) presented as a poster*
Does not include platform presentations or lightening orals.
Year and Abstract Title*
NACCT Abstract(s) presented as platform or lightening oral*
Year and Abstract Title*
Service to AACT or Affiliated Societies
AACT Webinar Presenter*
Includes ABAT Webinars
Date, Section or Webinar Title, and Presentation Title*
(e.g Pediatric Section Webinar, ABAT Journal Club)
Have you served as Editor of Clinical Toxicology*
Provide Years of Service*
Have you served on the Editorial Board for Clinical Toxicology*
Provide Dates of Service*
Have you served as a reviewer for Clinical Toxicology*
List each year served*
Have you served as an AACT Tox Coach Program Mentor?*
Provide Dates of Service*
Have you served as a member of the Advanced Hazmat Life Support Scientific Advisory Committee*
Provide Dates of Service*
Have you served as an Advanced Hazmat Life Support Instructor*
Provide years of service and number of courses per year*
EAPCCT Committee Chair*
Provide years of service*
EAPCCT Committee member with active participation*
Dates of Committee membership and Contribution to committee*
EAPCCT Symposium Speaker*
Provide name and date(s) of each lecture or presentation*
Other AACT Sponsored Activity Chair*
Dates of Service and Activities*
Describe any other AACT Sponsored Activities that you chaired.
Other AACT Sponsored Activity Participant*
Participation in AACT Sponsored Activity*
Describe any participation in AACT sponsored activity. Be specific and include date(s) of service.
AACT Representative for Sponsored Activity of Other Organization*
e.g. AACT Liaison
Provide years of service and describe activity*
AACT Questions of the Day Writer*
Minimum 5 questions per year to qualify
Provide number of questions/year*

Fellow of the AACT Application

Step 1 of 3

Contact Information for Applicant

Nomination Letter

Recommendation Letters

Service to AACT Core Functions

NACCT Participation

Service to AACT or Affiliated Societies

Other Sustained Contributions to Toxicology

Get Involved

Support AACT