Active Membership Application

* Source Code: MA08MGM MA08KAFP MACME06 MA07DROP MA08IMG MA08NEW1 MA08NEW4 MAPARTMEM Don't know Other

* Required

* Date of Birth:

* Gender: Male     Female

* Professional Address


City:     Choose State Alabama Alaska Arizona Arkansas Armed Forces Africa/Canada/Europe/Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Foreign Countries Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Uniformed Services Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip:

* Home Address


City:     Choose State Alabama Alaska Arizona Arkansas Armed Forces Africa/Canada/Europe/Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Foreign Countries Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Uniformed Services Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip:

* Preferred mailing address: Professional     Home

* Telephone
Office:     Home:

* Fax:

* E-Mail Address:

Licensure: Choose State Alabama Alaska Arizona Arkansas Armed Forces Africa/Canada/Europe/Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Foreign Countries Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Uniformed Services Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Expiration Date: License No.:

Are you currently certified by the American Board of Family Medicine (ABFM) through a reciprocity agreement between the ABFM and a foreign college of family medicine or general practice? Yes    No

Have you ever been denied membership in a county or state medical society; had your license suspended or revoked, voluntarily surrendered your license, or, have been convicted of a felony or violation of any state or federal narcotics act? Yes    No
(If yes, please explain.)

Are you now engaged in family medicine? Yes     No
Date you entered family medicine:

If you have previously held membership in AAFP, please indicate type, date, and constituent chapter affiliation:
Student     Resident     Affiliate     Active     Supporting     Inactive
Last year you were a member:     Choose State Alabama Alaska Arizona Arkansas Armed Forces Africa/Canada/Europe/Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Foreign Countries Georgia Guam 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Uniformed Services Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Comments

In submitting this application form, I certify that the above information is correct and complete and do hereby agree to abide by the Bylaws of the American Academy of Family Physicians and the bylaws of my constituent chapter. I understand that any money submitted will be refunded if my application is not approved. I understand that by providing my mailing address, e-mail address, telephone numbers, and fax number, I consent to receive communications sent by or on behalf of the AAFP (and its subsidiaries and affiliates) via regular mail, e-mail, telephone, or fax. I understand that the AAFP will not share my e-mail address, telephone number, or fax number with other organizations.

If applicant has never been an Active or Supporting FP member, or has not held Active or Supporting FP membership within the last two years, CME credits are not required. If the applicant has held Active or Supporting FP membership within the last two years, the applicant must provide evidence of 100 approved CME credits completed during the two years immediately preceding application. Please submit CME records to AAFP, Attn: Membership Records Dept., 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672. You can also fax your CME records to Attn: Membership Records Dept., (913) 906-6088.