Membership Application Membership Application Applicant Information First Name (required) Middle Initial Last Name (required) Degrees (required) Choose the Discipline that you believe best represents your focus. (required) This may be different from your deptartment. Basic ScienceObstetrics/GynecologyPediatrics Membership Category Applying for (rquired) FullAssociateCategory Determined by Council Current Academic Title (required) i.e. Asst. Professor, etc. Department (required) Institution (required) Address (required) City (required) state (required) zip (required) Phone (required) Email (required) Date of Birth (required) Important Documents (required) CV or NIH style Bioskech PDF or Word only Candidates Statement Please upload a one page statement on the research program or plans towards developing an independent program as it relates to the interests of the Perinatal Research Society. PDF or Word only Nominators Nominator Name (required) Institution (required) Email (required) Seconder Name (required) Institution (required) Email (required)