International Membership Application

* Required

* Name:
	First	Middle	Last	Previous (if applicable)

* Gender: Male Female

* Date of Birth:

* Professional Address

City / Province: Postal Code:

* Home Address

City / Province: Postal Code:

* Preferred mailing address: Professional Home

* Telephone
Office: Home:

* Fax:

* E-Mail Address:

Education
		Name of Institution/Program	City/State or Country	Degree	Graduation Date	Level of Training (If still in training)
*	Medical
	Family Medicine Residency Program
	Internship
	Fellowship
	Other Training
	Other Training

Licensure:
Country, Province:
Issue Date:
Expiration Date:
License No.:

Are you now engaged in family medicine? Yes No
Date you entered family practice:

Current Practice Activities
Clinical	Teaching	Administration

Are you currently in training? Yes No

If you have previously held membership in AAFP, please indicate the date of your last membership:
Last year you were a member:

Comments

In submitting this application form, I certify that the above information is correct and complete and do hereby agree to abide by the Bylaws of the American Academy of Family Physicians and the bylaws of my constituent chapter. I understand that any money submitted will be refunded if my application is not approved.

If you have any questions regarding International Membership, please contact the Membership Records department via e-mail at membweb@aafp.org or by calling 913-906-6000, Ext. 7671.