Online Application PDF Print E-mail

Online Application Instructions


  1. Complete the following application and click the "Submit" button.
  2. Students, Interns and Residents are required to complete the sections concerning medical school, graduation date, and institution of internship or residency but this information is also of interest to our other members when searching the directory.
  3. Carefully review the information in the application and read the statement of commitment at the end of the application.
  4. Click the "Submit" button again to submit the final application.
  5. Dues may be paid online or by mail.

Note: International applicants must email the College for special instructions: acopadmin@gmail.com.


AMERICAN COLLEGE OF PEDIATRICIANS
P.O. Box 357190,
Gainesville, FL 32635-7190
Application for Membership

 
NAME:
First:     Middle/Maiden:  
Last:  
Suffix:
Prefix/Title: Mr. Mrs. Ms. MD DO
Date of Birth (MM/DD/YYYY):
Gender: Male Female
Username:
Password:
Verify Password:
ADDRESS
Office Street:   Home Street:
Office Suite:   Home Apt#:
Office City:   Home City:
Office State:   Home State:
Office Zip:   Home Zip:
Office Country:   Home Country:
To which address would you prefer the College send all mailings? Office Home
Which method of correspondence do you prefer? Email US Mail
Practice Name:
Email:
Home Phone:
Office Phone:
Fax Number:
Licensing State:
License Number:
EDUCATION
Undergraduate School:
Graduation Date:
Degree Obtained:
Medical or Graduate Professional School:
Year Graduated:
Degree Obtained:
Institution of Internship/Training:
Location (City, State, Country):
If Other, Specify:
Training Period: (Year started to Year Completed)
Institution of Residency Program:
Location (City, State, Country):
If Other, Specify:
Training Period: (Year started to Year completed)
Institution of Fellowship Program:
Location (City, State, Country):
If Other, Specify:
Year Started:
Year Completed:
BOARD CERTIFICATION Yes No
Name of Board:
Date Certified:
Expiration Date:
SUB-SPECIALTY OR
SURGICAL BOARD CERTIFICATION		 Yes No
Name of Board:
Date Certified:
Expiration Date:
SPONSORS - Do you know of any College Fellows?   Yes No
Name: Phone
Name: Phone
MEDICAL CAREER ACTIVITIES
Detail your professional activities after training through the present. Attach an explanation of further activities, if necessary.
Type: Practice Teaching Research Other
Location:
Dates:
Type: Practice Teaching Research Other
Location:
Dates:
Type: Practice Teaching Research Other
Location:
Dates:
MEDICAL LICENSURE
Have you ever been disciplined by any professional board which resulted in loss of licensure at any time? Yes No
Have you ever been convicted of a felony crime? Yes No
Have you ever lost your privileges at any hospital? Yes No
PRACTICE SETTING - (This information will be used for internal purposes and will remain confidential)
Indicate your primary practice setting:
Solo practice
Pediatric/Multispecialty group practice
University hospital/medical school
Outpatient pediatrics only
Inpatient pediatrics only
Government hospital/clinic (military or other)
Missionary practice
Other
Indicate your primary practice location:
Urban, inner city
Urban, non-inner city
Suburban
Rural
Other
Race/Ethnicity:
Language(s) Spoken:
English
Spanish
German
Italian
Russian
French
Hebrew
Arabic
Chinese
Japanese
Vietnamese
Laos
Other
Additional Comments: