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Editorial Committee Application
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Basic information
-
Step
1
of 5
Name
*
First
Last
Are you a headache fellow or AQH or UCNS certified?
AQH
UCNS
Headache fellow
Not applicable
Credentials
*
Email
*
Phone
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred pronouns (optional)
LinkedIn / professional webpage URL (optional)
Next
Current employer/organization
*
Current job title
*
Are you currently licensed to practice?
*
--- Select Choice ---
Yes
No
Not applicable
Next
Briefly describe your relevant experience
*
Expertise categories (select all that apply)
*
Migraine
Headache disorders (general)
Pediatric headache
Women’s health / hormonal migraine
Neurology
Pain medicine
Behavioral health / psychology
Sleep
Pharmacology / therapeutics
Devices / neuromodulation
Public health / epidemiology
Health policy / access to care
Other (text)
Please explain
*
Topics you do not feel comfortable reviewing (optional)
Next
Upload bio/headshot (optional)
Drag & Drop Files,
Choose Files to Upload
You can upload up to 2 files.
Upload CV/resume (optional)
Drag & Drop Files,
Choose Files to Upload
You can upload up to 2 files.
Next
Checkboxes
*
I understand this is an advisory review role and NHF retains final editorial decision-making.
Checkboxes (copy) (copy)
*
I understand participation is voluntary
Checkboxes (copy)
*
I agree to abide by the terms of the National Headache Foundation Confidential Information Policy.
Checkboxes (copy) (copy)
*
I agree to disclose conflicts of interest and recuse myself when appropriate.
Signature
*
Clear Signature
/ do (optional)
Date / Time
*
Date
Time
Submit
