Application for Listing in Registry of Anatomical Educators
Name: (First, M.I., Last)
Highest Degree Held:

MD

PhD

MBBS

Other
Institution and Date of Highest Degree:
Present/Most Recent Position:
Title/Rank at that Position:
Current Mailing Address:

Street:

City:

Country:

State: Zip/Postal Code:

Phone Number:
Fax Number:
E-mail Address:
Affiliation? You MUST belong to one of these 3 organizations.

AACA

BACA

AAA

Teaching Awards (special recognition):
Willing to Teach Anywhere?

Yes

No

Preferred Regions:
Willing to Teach at Any Time of the Year?

Yes

No

Preferred months:

List Courses You Can Teach: (ie. gross anatomy, histology, etc.)
Have You Been a Course Director?

Yes

No

Course(s) Directed:
List Programs You Have Had Experience Teaching (ie. Med, Dent, PA, PT, etc.):
Names of Referees: