ACOP Membership Application


Required fields are marked in red.

First Name:
Middle Initial: (if any)
Last Name:
Title(s):
 
Gender:
male
female
 
E-Mail Address:
 
Contact Preference:
mailing
billing
 
Please mark which address
you would like in a published
directory and the website:
Mailing
Billing
Neither

Mailing Address
Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Cell Phone Number:
Phone Number:
Fax Number: (if any)

Billing Address
Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Phone Number:
Fax Number: (if any)

Doctoral and Postdoctoral Training
Please provide a chronological listing of your training including military service.
 
Internship Institution:
Internship Location:
Begin Date:
/ (MM / YYYY)
End Date:
/ (MM / YYYY)
 
Residency Institution:
Residency Location:
Begin Date:
/ (MM / YYYY)
End Date:
/ (MM / YYYY)
 
Residency/Fellowship Institution:
Residency/Fellowship Location:
Begin Date:
/ (MM / YYYY)
End Date:
/ (MM / YYYY)
 
Are you board eligible:
yes
no
 
Are you board certified:
yes
    
AOBP
  Date: / (MM / YYYY)
ABP
  Date: / (MM / YYYY)
no
 
Subspecialty:
 
Area of Special Interest:
 
Academic Affiliations:
 
Hospital Staff Positions
Currently Held:
 
Primary Institutions and
Locations:
 
Other Hospital Affiliations:
 
Professional Society
Memberships (specify if
you are an officer):
 
Are you an AOA
member? (not required
for membership)
yes
no
Membership #:
 
Are you an AAP
member? (not required
for membership)
yes
no
Membership #:
 
Education
Medical School:
 
Graduation Date:
/ (MM / YYYY)
 
Undergraduate Education
Institution:
Location:
Begin Date:
/ (MM / YYYY)
End Date:
/ (MM / YYYY)
 
For Student Membership Applicants Only
Student Club: (required for student membership)
ACOP Student Club Faculty Liason: Phone:
ACOP Student Club President: Email:
 
Membership category:
Fellow ($400)
Associate ($400)
General ($400)
Candidate: Intern ($20)
Candidate: Resident / Fellow-in-Training ($30)
Student ($30 one time only fee)
 

All applications will be reviewed by ACOP, and applicants
will receive prompt notice when approved. the application
process takes approximately two months.
Payment
 
Card Type:
no debit cards accepted
VISA
MasterCard
Discover
American Express
 
Name on Card:
Card Address:
Card Number:
Card Zip Code:
Security Code:
Expiration date:
/

Note: This is a secure transaction system. However, additional documentation must be provided. Please provide: Copy of state license and proof of board certification, if applicable. For interns and residents: Note from program director indicating participation in an approved training program. Please submit this documentation via email to ACOP@ACOPeds.org, via fax to (804)282-0090, or via mail to ACOP, 2209 Dickens Rd., Richmond, VA 23230-2005.

If accepted for membership, I agree to abide by the Code of Ethics and the Constitution and Bylaws of ACOP. By submission of this document, I authorize release of the information contained herein and in membership files of those organizations and hospitals to which I may subsequently apply for membership; and the release to ACOP by organizations and hospitals of information relative to my previous membership in those organizations. I am a resident or licensed physician in compliance with the state board of medical licensure and/or discipline's order.

American College of Osteopathic Pediatricians
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