ACOFPCA Resident Membership Application
First Name *
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Middle Initial
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Last Name *
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Previous Name
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Email Address *
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Phone Preference *
Home Phone *
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Cell Phone *
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Home Address *
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City *
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State *
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Zip *
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What is the name of your residency program? *
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Residency Program Address *
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City *
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State *
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Zip *
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What date did you start your residency? *
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What date do you anticipate completing your residency? *
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Resident Membership Category *
What College of Medicine did you attend? *
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What was your COM graduation year? *
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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 California. I agree to accept the Board of Governors of ACOFPCA as the sole and only judge of my qualifications to be and remain a member.
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