Select One:
          I would like to apply for a new membership. (application will be processed upon receipt of membership fee)
          I would like to pay my dues and renew my membership - Please verify/update information for my membership/program listing.  ( Member Number optional)
          My dues are current - Please update information for my membership/program listing.  ( Member Number optional)
          Please list my program. (I do not want to apply for ANDP membership at this time. I understand that the fee for nonmembers is $265.00)

Part A - PROGRAM INFORMATION

Name of Member Program or Department:    
         

Type of Program:
          Undergraduate

Institution:
         

Program Web Address (URL):
         

PhD Degrees or Programs Available: (e.g., Neurobiology, Psychology, Neuroanatomy, Neuropharmacology)

a.
b.
c.

Part B - PROGRAM OR DEPARTMENT CHAIR/DIRECTOR

Title:
          Department Chair
          Program Director
          Program Coordinator
          Other  

Name:
               Degree: 

Mailing Address:
         

City:        State:      Zip Code:       Country: 

E-mail Address:
         

Telephone Numbers:
          Phone:        FAX:   

Part C - CONTACT INFORMATION FOR ANDP BUSINESS (See Part D to list contact information for queries by students and other interested parties)

     PRIMARY CONTACT  (receives dues notice, ballots, and all ANDP announcements)  

Title:
          Department Chair
          Program Director
          Program Coordinator
          Other  

Name:
               Degree: 

Mailing Address:
         

City:        State:      Zip Code:       Country: 

E-mail Address:
         

Telephone Numbers:
          Phone:        FAX:   

 

     SECONDARY CONTACT  (receive informational mailings but not dues notices or ballots)

Title:
          Department Chair
          Program Director
          Program Coordinator
          Other  

Name:
               Degree: 

Mailing Address:
         

City:        State:      Zip Code:       Country: 

E-mail Address:
         

Telephone Numbers:
          Phone:        FAX:   

 

     ADDITIONAL CONTACT  (There is a $20 charge for each additional contact)

Title:
          Department Chair
          Program Director
          Program Coordinator
          Other  

Name:
               Degree: 

Mailing Address:
         

City:        State:      Zip Code:       Country: 

E-mail Address:
         

Telephone Numbers:
          Phone:        FAX:   

 

Information submitted below, in Parts  D and E, is published in the Directory of Neuroscience Training Programs on the ANDP website.

Part D - CONTACT INFORMATION FOR EXTERNAL QUERIES (Information is published in the Directory of Neuroscience Training Programs on the ANDP website) 

Title:
          Department Chair
          Program Director
          Program Coordinator
          Other  

Name:
               Degree: 

Mailing Address:
         

City:        State:      Zip Code:       Country: 

E-mail Address:
         

Telephone Numbers:
          Phone:        FAX:   

Part E - PROGRAM DESCRIPTION   (Information is published in the Directory of Neuroscience Training Programs on the ANDP website) 

Year Established:
         

Total Number of Faculty (Spring 2006):
         

Total Number Enrolled Full-Time Students (Spring 2006):
         

Demographics:

a. % US Citizens:  
b. % Female:  
c. % US Under-Represented Minorities:   

i. % Native Americans: Indian, Hawaiian, Alaskan or Pacific Islander:   
ii. % African American/Black (not of Hispanic origin):  
iii. % Hispanic or Latino Origin:  

Total Number of Graduates in the Last Five Years:
         

Number of Faculty Who Have Supervised Graduate Student Theses Projects in Their Labs in the Last Five Years:
         

Average Number of Years Taken by These Graduates to Complete the Program:
         

Admission Requirements:
         

How or Where to Apply for Admission:
          

  Annual Tuition and Fees Costs:
         

   
Approximate Cost of Living per Year:
         

Housing Availability and Costs per Year:
         

Daycare Facilities Availability and Costs per Month:
          

Stipend/Assistantships and Financial Assistance:
          

How, if Necessary, to Apply for Stipends/Assistantships and Financial Assistance:
          

  Written Descriptor of Program - Limited to 300 Words.
            Please include all information about formal and informal training activities in Neuroscience
            (You may e-mail (cindyburks@andp.org), mail or FAX your written descriptor, if necessary)
          

Part F - AUTHORIZATION

Date of Submission:   

Person Submitting Application:
          Name
          Title  

Part G - PAYMENT

Method of Payment:
          No Payment Required (This is a membership/program update and my dues are current)
          Check  Make check payable to Association of Neuroscience Departments and Programs; mail check to
                    Ms. Cynthia A. Burks
                    ANDP
                    41218 Roundup Road
                    Magnolia, TX  77354
          Credit Card  (Complete and submit credit card information below.  This information is submitted using a secure connection.)