ACOFP Student Member Application
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
AOA ID
Your answer
Student Year for 2018-2019 academic year *
COM *
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Phone
Your answer
Email *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Have you ever been denied membership? *
Have you ever been denied membership in a County/District of State of Osteopathic Society 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.
Your answer
If you have any questions, please contact the ACOFP Membership Department.

Membership Department
800-232-0794
membership@acofp.org.

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