Resident Membership Application
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Previous Name
Your answer
Email Address *
Your answer
Phone Preference *
Home Phone *
Your answer
Cell Phone *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Residency Program Address
Your answer
City
Your answer
State
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Zip
Your answer
What College of Osteopathic Medicine did you attend? *
Your answer
What was your graduation year? *
Your answer
What is the name of your residency program? *
Your answer
What date did you start your residency? *
Your answer
What date do you anticipate completing your residency? *
Your answer
Resident Membership Category *
ACOFP Resident Membership is complimentary.
Have you ever been denied membership? *
Have you ever been denied membership in a County/District of State of Osteopathic Society; had your license suspended or revoked; or have you been convicted of a felony or violation of any state or federal narcotics act?
Signature *
In signing this form, I certify that the information provided is correct and complete, and do hereby agree to abide by the Constitution and Bylaws of the American College of Osteopathic Family Physicians. I agree to accept the Board of Governors of ACOFP as the sole and only judge of my qualifications to be and remain a member. I understand that any money submitted will be refunded if my application is not approved.
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