Society for Epidemiologic Research (SER)

SER
PO Box 990
Clearfield, UT 84089
Phone: 801-525-0231
Fax: 801-774-9211
email: membership@epiresearch.org

Regular Membership (HALF YEAR)- $95.00
Student Membership (HALF YEAR)- $50.00
Emeritus/Retired Membership (HALF YEAR)- $50.00
Student Discount Rate ***** - $25*
*This rate does NOT** include a subscription to AJE or online access to AJE. For a list of student membership benefits, click here.

Fields in RED and BOLD are required.
First Name:
Last Name:
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Member# (if known)
Current Professional or Student Affiliation:

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Request for Demographic Data

Beginning this year, the SER Executive Committee would like to periodically gather demographic data on our membership. This information is important because it will enable us to track changes in the composition of SER membership and identify members' research interests. It will also help us develop more targeted programs and recruitment efforts.

As always, participation in these brief and confidential surveys is optional, though a high response rate will certainly increase the value of the data. Very general demographic profiles of SER membership will be published, periodically, in the Newsletter and on the SER website.

We are requesting the following information. Participation in this survey is optional.

Age	<40 ; 40-49; 50-59; >=60
Sex	Male Female
Race/Ethnicity (check as many as apply)	White Black/African american Hispanic Asian American Indian/Alaskan Pacific Islander Other:
Employment Type	Academics Federal Government State or local Government Industry Independent Consultant Private Research Firm Other employment
Primary Research Area (Choose as many as apply)	Aging Behavioral Cancer Cardiovascular Chronic Disease Clinical Diabetes Drug Use Environmental Genetics Health Services Infectious	Injury Methods Neuro Epi Occupational Pediatric Perinatal Psychiatric Reproductive Social Women's Health Other:
Disciplinary Training (Check as many as apply)	BA or BS MPH MD RN Doctorate (PhD, DrPH, ScD, etc) DVM DDS Other:
Year of last Degree (e.g. 1999; 2002)
If you are a new member, how did you hear about SER?
Why did you join SER?

PAYMENT METHOD:

NOTE: If you wish to pay be credit card, please submit this form and then follow the instructions on the next screen. If you wish to pay by check you will be invoiced upon receipt of this renewal. REMINDER: Memberships will not be activated until payment is received.)

This form can be printed and mailed, faxed or emailed to:

SER
PO Box 990
Clearfield, UT 84089
Phone: 801-525-0231
Fax: 801-525-6549
email: membership@epiresearch.org

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