Application for Institutional Affiliation
We request consideration for Institutional Affiliation at the following level (check one):
CATEGORY A (Fee is $50 US)
Subscription to the Journal of the International Neuropsychological Society (JINS)
INS mailings
One individual eligible to attend INS meetings (at reduced rate)
CATEGORY B (no fee - greater need must be demonstrated)
Subscription to JINS, based on availability
INS mailings
One individual eligible to attend INS meetings (at reduced rate)
I, (name of Corresponding Member) ________________________________________________,
declare that (name of society or organization _________________________________________
wishes to become an Institutional Affiliate of the International Neuropsychological
Society at the level indicated above. In witness thereof the Chairperson/President
and Secretary of the organization provide their signatures below. In my capacity
as Corresponding Member, I hereby agree to:
1) attach to this application a list of the members of our organization who have
an interest in neuropsychology, and who wish to be included in this group/institutional
affiliation.
2) attach an endorsement of need. I understand that Institutional Affiliation
is available to groups from developing countries/regions.
3) attach a statement of intent assuring
a)that all the individual members on the attached list will be advised of the
availability of the journal at the designated library,
b) the public will maintain access to the journal at the designated library, and
c) all mailings received from INS will be disseminated among the listed individuals.
4) attach a list of the names and addresses of the principal university libraries
in my country.
5) enclose annual dues of $50 (USD) - CATEGORY A only
Unfortunately, we are currently unable to accept payment via the internet.
Please print and mail completed form with attached documents and payment to the
address below.
I understand that Institutional Affiliation is renewable up to a total of three consecutive years. A completed application is due at the end of each calendar year in order to renew affiliation status for the next year. Any application submitted after July 1 can either be held until December to be processed for the next year, or it can apply to the current year, provided that the group agrees to renew its affiliation for the next year. At the end of the three years, those persons who have been listed on a particular Institutional Affiliation will be invited to join INS via official categories of individual membership. If, at that time, any interested individuals face continued regional economic hardship, they are invited to approach the ILC for possible assistance, which will be based on availability and demonstrated need.
I understand that individuals associated with INS via the Institutional Affiliation category are not eligible to hold office in INS or vote in INS elections.
I understand that Institutional Affiliation includes:
1)JINS SUBSCRIPTION Category A - One year subscription to the Journal of the International
Neuropsychological Society included or Category B - Placement on a list to receive
a donated subscription to the Journal of the International Neuropsychological
Society. Availability of donated subscriptions cannot be guaranteed. For Categories
A and B, the journals must be housed in a library with public access. The designated
library for receipt of this subscription is:
Name of Library ______________________________________________________
Postal Address ________________________________________________________
____________________________________________________________
_____________________________________________________________
To the attention of ______________________________________________
2) ALL INS MAILINGS These materials should be sent to the attention of the Corresponding
Member, at the following address: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
telephone number ___________________________________
fax number _________________________________________
e-mail address ______________________________________
3) ATTENDANCE AT MEETINGS One representative will be eligible to attend INS meetings. Registration fee for INS meeting attendance will be equal to that of an Associate Member. The attending representative will be designated by the Institutional Affiliate organization itself, but must be an individual whose name appears on the attached list. A different representative may attend a subsequent meeting, provided that his/her name is also on the attached list. Changes may only be made to this list once per year, at the time of affiliation renewal.
President/Chair (print)________________________
(signature)________________________(date)__________
Secretary (print)________________________
(signature)________________________(date)__________
Corresponding Member (print)________________________
(signature)________________________(date)__________
Please return completed form and payment to:
Robert A. Bornstein, PhD, Executive Secretary,
International Neuropsychological Society,
700 Ackerman Road, Suite 625
Columbus, OH 43202
U.S.A.