ACOFPCA Student Membership Application
Email address *
FIRST NAME *
Your answer
MIDDLE INITIAL
Your answer
LAST NAME *
Your answer
STUDENT YEAR FOR 2019-2020 ACADEMIC YEAR
CALIFORNIA COM ATTENDING *
Required
STREET ADDRESS *
Your answer
CITY *
Your answer
STATE *
Your answer
ZIP *
Your answer
GENDER *
Cell Phone Number *
Your answer
Anticipated Month and Year of COM graduation *
Your answer
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 Physician of 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. I understand that any money submitted will be refunded if my application is not approved.
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