ACP Membership Application

* Required field

Personal Details * Address type
Contact Details I wish to be excluded from non-ACP-related mailings I wish to be part of the following U.S. Armed Forces ACP Chapter
Recruiter Details
Practice Details
Self-designated Specialties

Please indicate as your "principal" specialty/subspecialty the area in which you spend most of your time. As your "secondary" specialty/subspecialty, indicate the one in which you spend the next most amount of time (If applicable).

Training Details
* Medical School

If you've graduated internationally, please choose 'Other' from the 'State/Province' dropdown menu.

School Name City State/Province
Country Year Graduated Degree Earned
* Training/Board Status
* Board Name* Certification/ Recertification Year Expiration Year
Optional Information

Applicant Please Note: The following information will help provide ACP with accurate membership statistical data but will not be considered in connection with your application for Membership. Completion is optional.

* Special First-Year Membership Dues Rates

To Ensure Membership through June 30, 2017. [i]

New Members United States
9 or more years out of medical school
8 or less years out of medical school
* Disclaimers

The candidate should read the following statements and check where indicated.

Licensure
Attach a detailed explanation, including current status, of any issue(s)
* Ethics
* Credentials
* Credit Card Payment

[i] The allocation of chapter dues is waived for new Members. Upon membership renewal, annual dues will include fees to support both the national ACP and your local chapter. For the renewal dues rate in your chapter, please visit ACP's dues page or call Customer Service at 800-523-1546, ext. 2600, or direct at 215-351-2600 (M-F 9:00 a.m. to 5:00 p.m. EST)..