Resident Membership Application

* Required

* Name:
	First	Middle	Last	Previous (if applicable)

* Gender: Male Female

* Date of Birth:

* Professional Address

City: Zip:

* Home Address

City: Zip:

* 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

Name of Residency Program Director:

Licensure:
State:
Expiration Date:
License No.:

Have you ever been denied membership in a county or state medical society; had your license suspended or revoked, voluntarily surrendered your license, or, have been convicted of a felony or violation of any state or federal narcotics act? Yes No
(If yes, please explain.)

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. I understand that by providing my mailing address, e-mail address, telephone numbers, and fax number, I consent to receive communications sent by or on behalf of the AAFP (and its subsidiaries and affiliates) via regular mail, e-mail, telephone, or fax. I understand that the AAFP will not share my e-mail address, telephone number, or fax number with other organizations.