* Last Name: |
Last Name is required |
* First Name: |
First Name is required |
Middle Name: |
Middle Name is required |
* Degree: |
Please select degree |
* Mailing Address: |
(Street Address)
Address is required |
* City: |
City is required |
* State: |
Please select State |
* Zip Code: |
ZIP Code is requiredInvalid format. |
* Phone: |
(123-555-1234)
Phone is requiredInvalid format. |
* Email Address: |
(abc@example.com)
Email is requiredInvalid format |
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Office Information |
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Office Address: |
(Street Address)
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City: |
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State: |
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Zip Code: |
Invalid format |
Office Phone: |
(123-555-1234)
Invalid format |
Office Fax: |
(123-555-1234)
Invalid format |
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Residency Training Information |
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* Type of Training Program: |
Training Program is required |
* From Date: |
(mm/dd/yyyy)
From Date is requiredInvalid format |
* To Date: |
(mm/dd/yyyy)
To Date is requiredInvalid format |
* Institution Name: |
Institution Name is required |
* Institution Address: |
(Street Address)
Institution Address is required |
* City: |
City is required |
* State: |
Please select state |
* Zip Code: |
Zip Code is requiredInvalid format |
Other Residency Training |
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Type of Training Program: |
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From Date: |
(mm/dd/yyyy)
Invalid format |
To Date: |
(mm/dd/yyyy)
Invalid format. |
Institution Name: |
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Institution Address: |
(Street Address)
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City: |
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State: |
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Zip Code: |
Invalid format |
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Fellowship Training Information |
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Type of Training Program: |
Training Program is required |
From Date: |
(mm/dd/yyyy)
From Date is requiredInvalid format |
To Date |
(mm/dd/yyyy)
To Date is requiredInvalid format |
Institution Name : |
Institution Name is required |
Institution Address: |
(Street Address)
Institution Address is required |
City: |
City is required |
State: |
Please select state |
Zip Code: |
Zip Code is requiredInvalid format |
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Board Certification Information |
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Specialty 1: |
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Specialty 2: |
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Professional & Ethical Standards Information |
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Note: |
If you answer yes to any of the following questions please provide details at the space provided below. |
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1 - Do you have any restrictions on your current state medical license? |
* Restrictions: |
Please make a selection. |
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If your answer is yes please provide details below. |
Provide Details: |
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2 - Have you ever been convicted of any felony charges? |
* Convicted: |
Please make a selection. |
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If your answer is yes please provide details below. |
Provide Details: |
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3 - Have you ever been declined a membership to join any other professional/state medical board or society? |
* Declined a Membership: |
Please make a selection. |
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If your answer is yes please provide details below. |
Provide Details: |
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* Verification Code: |
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Please enter the above two words of code. |
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Membership Dues Information |
FREE complimentary membership for first two years |
Please allow ten business days for your application to be processed. |
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I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that falsified statements on this application can be grounds for termination of my ACUCP membership. |
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When you have finished, simply click the "Submit Application" button.
(It may take a few moments, and you will receive confirmation on your screen.) |
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Note: - Please verify the required fields (*) before registration! |
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