New Fellow Information Request

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12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Contact Information

Name

First

Middle

Last

Suffix

Mailing Address

Primary Address Type

Mailing Street

Mailing City	Mailing State/Province
Mailing Zip/Postal Code	Mailing Country

Affiliation

Primary Affiliation

If -Other- selected

Title

Bio Link from your affiliated institution

Discipline	If -Other- selected
Field	If -Other- selected

Email and Phone

Preferred Email	Email
Preferred Phone	Phone

Social Media

Twitter/X Handle

Profile URL

LinkedIn Handle

Profile URL

Additional Contacts

Assistant Name	Assistant Email
Email my annual dues to:

In one brief sentence, summarize your proudest accomplishment in a way that would help a general audience understand the impact of your work (20 words or less)

Please upload a headshot and, if necessary, an audio file with the correct pronunciation of your name. Alternatively, you can send these items to members@academyofinventors.org

Please provide a headshot to use for Induction Ceremony

Please enter the phonetic spelling of your full name here

Provide an audio file (mp3, mp4, m4a, flac, wav, wma, aac) with your name's correct pronunciation

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AAAS Fellow	AIMBE Fellow	IEEE Fellow	NAE Member
NAM Member	NAS Member	AAA&S Member	Nobel Laureates
Draper or Wolf Prize	U.S. Medal of Science/Tech. & Innovation	National Inventors Hall of Fame	Lemelson-MIT Prize