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Application for Membership

 

I hereby apply for membership in the component association of the state in which I have my principal practice and to the American Podiatric Medical Association (APMA). If elected, I agree to uphold and abide by the purposes, constitution and bylaws, code of ethics, and all rules and regulations of my component association and the APMA. I understand that no one has an automatic right to be elected to membership in this voluntary organization.
Last Name    First    Middle 
Previous Last Name (Changed due to marriage, divorce, etc.) 
Birth Date  /  /    Nickname 
Social Security No. (Optional):       Sex:  M   F
Ethnic Group (for demographic use only):   White   Black   Hispanic   American Indian   Asian/Pacific
Spouse's Name         US Citizen (Optional):  Yes  No
Practice Name 
Practice Type:  Solo Practitioner   Partnership   Podiatric Medical Group   Multi-Specialty Group
 HMO   VA   Military   Educational Institution   Other 
Your Status in the Practice:  Owner  Employee 
Complete all Addresses below.
Check only one for all APMA mailings.
Home Address: 
City:   State:   Zip: 
Telephone: (  )   Fax: (  ) 
Principal Office/Residency Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Second Office Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Third Office Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Fourth Office Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Fifth Office Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Sixth Office Address: 
City   State   Zip 
Telephone: (  )   Fax: (  ) 
Education
Undergraduate
Degree 		Yes  No       If yes, complete
Year    State    Institution    Degree 
Graduate
Degree 		Yes  No       If yes, complete
Year    State    Institution    Degree 
Podiatric Medical
Degree 		Check College Below     Year of Graduation 
 Barry    CCPM    Iowa    NYCPM    OCPM    PCPM    Scholl  
 Other  
Postgraduate
Education 		Yes  No       If yes, complete
 Residency:    RPR    POR    PPMR    Preceptorship  
 PSR:    PSR 12    PSR 24    PSR 24+  
State Begin Date: mo /  yr  
Institution Completion Date: mo /  yr
 
State Begin Date: mo /  yr  
Institution Completion Date: mo /  yr
Military
Military
Service 		 USA    USAF    USN    USMC    USCG   Other 
Date Entered    Date Separated    Current Rank 
 Reserves     If yes, Branch of service 
Professional Licensure
Podiatric Medical
Licenses 		Year    State    Number 
Year    State    Number 
Year    State    Number 
Have you ever had a license to practice podiatric medicine suspended or revoked in any state?
 Yes    No       If yes, please explain below:
Are you currently on probation, suspension, or investigation by any licensure authority, state or federal agency?
 Yes    No       If yes, please explain below:
Professional Medical Practice
Original Practice
Start Date 		Month     Day     Year 
(Hospitals, HMOs, PPOs, Nursing Homes)
Affiliation Year    State    Institution     Hosp    PPO    HMO    Nursing Homes
Year    State    Institution     Hosp    PPO    HMO    Nursing Homes
Year    State    Institution     Hosp    PPO    HMO    Nursing Homes
Year    State    Institution     Hosp    PPO    HMO    Nursing Homes
Board Certification (Click Here for Board Listings)
 ABPS    ABPO    ABPOPPM    Other 
Affiliated/Related
Membership 		(Click Here for Affiliated/Related Listings)
AAHP   AAPPM   AAPSM   AAWP   ACFAOM   ACFAP   ACFAS   ACPMR
ACPR   APCS   APMWA   ASPD   ASPM   COMMIT   Other 
Academic Rank  Adjunct    Clinical    Emeritus    Visiting    Instructor
 Associate Professor    Assistant Professor    Other 
 Part Time    Full Time
Dates    Institution
Consultant
        Insurance Carrier    PRO    UR Firm    Other 
Dates     Institution 
Previous Member of APMA
        Yes    No       If yes, complete
Dates     Component Association 
Please submit a sample of your stationery, business card and a copy of all state licenses with this application.
I understand that dual membership (state component and national associations) is required to be a member in good standing. I agree not to represent myself as a member of APMA or my component, if for any reason, I cease to be a member in good standing. I also understand that a portion of my annual dues is in payment for a one year subscription of $5 for the APMA NEWS and $29 for the Journal of the American Podiatric Medical Association. I agree that incomplete or false information may be grounds for denial or termination of membership.
APMA dues are not deductible as a charitable contribution for federal tax purposes but may be deductible as a business expense.
Unless you are in a residency program, please forward your completed application and dues payment directly to your component. Applications for resident membership should be sent directly to APMA, along with your dues payment.
Applicant Signature: ____________________________________________, DPM Date: ______________
I was recruited for APMA membership by the following APMA member: ___________________________
Click "CONTINUE" Below to verify your information and print this form for mailing.

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