Licensure Information Form

	Licensure Information Form
Upon completion of your residency training, it is necessary to transfer from resident status to active membership status. Simply complete this form AND submit for processing.

Name:

AAFP ID Number:

Medical License Number:

Date of Issuance:

Month
Year

State of Issuance:

Home:
Preferred

Street, apt. number

City
State
ZIP/Postal Code

Country

Phone Number

Fax Number

Email

Professional:
Preferred

Street, apt. number

City
State
ZIP/Postal Code

Country

Phone Number

Fax Number

Email

Effective Date:

Month
Year

Are you a graduating resident or fellow entering family practice?
Yes
No

Any questions, problems, or suggestions? Email contactcenter@aafp.org.