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 Address:
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