ACP American College of Physicians - Internal Medicine - Doctors for Adults

Note: Fields marked with * are required.

Please remember to make a copy of this form for your records

*Name:

*ACP ID #:

*Address:

*City:

State/Province:

ZIP/Postal:

Country:

*Contact Number:

*E-mail:

Please indicate the type of dues adjustment being requested:

Disability (Permanent/temporary adjustment)
Medical condition that seriously interferes with the ability to practice medicine and/or earn income.
Please indicate:

1. Permanent condition (personal physician’s note required)
   Temporary condition (temporary reduction only, renewable annually upon request)

2. Dues reduction (with publications)
   Dues waiver (no publications)

3. Medical condition:

4. Impact on employment:

5. Anticipated date of return to employment:
   Full time
   Part time

Financial Hardship (Temporary adjustment, renewable once upon review)
Sudden, unforeseen short-term financial difficulty resulting in substantial reduction of income.
Please indicate:

Dues reduction (with publications)
Dues waiver (no publications)

Please describe the circumstances for requesting this adjustment and how long and to what degree this will affect your ability to pay dues:

Retired/Semi-retired (Permanent adjustment, no renewal required)
Age 60 or older, fully retired or working 20 hours or less per week.
Please choose:

Dues reduction (with publications)
Dues waiver (no publications)

Part Time (Temporary reduction only, renewable annually upon request)
Under age 60, early retirement, unemployed, or working 20 hours or less per week.

*Date: