You are eligible for AGS Fellowship if you are currently an Active Member of the AGS and have been an Active Full Member of the AGS for at least 5 years and have attended at least 3 Annual Meetings.

Instructions: To be awarded the degree of Fellow, an applicant must:

1. Provide two letters of recommendation by members of the Society in good standing (members for at least three years, Fellows of the Society encouraged) endorsing the applicant's advancement to Fellowship status.
2. Accrue points as defined by this application.
   • Complete only the items that apply.
   • Submit documentation where noted.

CERTIFICATION

Certifying Body:
(put a couple of examples here)

Certified in (list all): Initial Certification Date:  

Recertification			Dates
Recertification			Dates

For Physicians Only
Geriatrics Certificate of Added Qualifications or geriatrics board certification)

AGS ACTIVITIES

List up to 5 AGS Annual Meetings that you have attended

List CE meetings sponsored by the AGS or AGS Affiliates that you have attended

List other AGS sponsored or AGS Affiliate sponsored CE activity that you participated in (such as webcast, online CE, journal CE, etc.)

List non-published research presented at an AGS sponsored or endorsed meeting

List other AGS activities that you have participated in (Volunteer mentor, Spokesperson, Health in Aging Advocacy Center, etc.)

List any positions held for the AGS (Committee, Board, editorial panel, workgroup, etc.)

List any activities where you have served as the AGS representative to another group (e.g., guideline reviewer, member of a work group, etc.)

List grants related to aging research, education or clinical activity received

PUBLICATIONS & RESEARCH

List authored Research or Clinical Review articles you have published in a peer-reviewed journal (such as the Journal of the American Geriatrics)

List articles that you have published in a non-peer reviewed medical publication

List if you have served as an author or on an editorial board for an AGS Publication, including print, online and patient education resources.

List other aging related publications that you authored (e.g., book chapters, pamphlets, etc.)

TEACHING

List participation as a speaker or moderator at an AGS National Meeting

List participation as a speaker or moderator at an AGS Affiliate Meeting

PUBLIC SERVICE

List any volunteer patient education activities related to care of older adults

Describe if you have performed any public relations activity that explains Geriatrics to the public such as lectures to civic groups, public service announcements, interviews, radio or TV appearances.

List any volunteer medical services related to older adults you performed

Service on Hospital, Health Care Systems, Community or Insurance Boards

List active participation in quality initiatives during your practice in the last 5 years

List if you have served as a chair, officer, committee member or delegate of another Health Professional organization such as AMDA, ACP, AAFP, ASCP, NCGP, etc.