Text Box: AFDMA – American FDM Association

Membership Application

 

Please complete all sections.                                                                       Board Action __________
Text Box: Name: DOB: Address: City: State: Zip: Phone: Fax: Email: AOA# / AMA#: State and License #: Mobile phone: Text Box: Practice Status: Private Practice Resident/Fellow Government/Military Faculty or Hospital Internship Other: Medical School & Graduation Date: Internship & Year Completed: Residency & Year Completed: Area of Practice: Certification: Other Professional Degree(s):

By my signature, I certify that the above information regarding my professional credentials is true and I authorize release of the information contained in this application and membership file to those organizations or hospitals to which I may subsequently apply for membership, and the release to AFDMA by organizations and hospitals of information relative to my membership in those organizations.

 

I agree to practice, comply, and govern my conduct in accordance with the Code of Ethics of AFDMA and AOA / AMA and such other standards of conduct and practice ethics adopted by the Association.

 

Signature ____________________________________________   Date ________________

 

 

AFDMA’s membership year is January—December, with membership expiring on December 31.

 

Membership Dues . . . . . . $200

 

                                  Payment: Check # _______ enclosed (Checks payable to AFDMA)

 

Mail Payment and Application to:

AFDMA c/o Marjorie Kasten, Executive Director, 360 Grandview Avenue, Bangor, ME 04401