To apply for membership:
1. Please complete all fields and sign application below.
2. Enclose your dues payable to ACP (or include credit card information on the application) and return by fax or mail.

Applicant Contact Information­­Applicant’s ACP # (if known)

nnnnnnnn
Code: ____________________

Last _______________________________ First __________________ MI____

DayYearnn nnnnDay
Year

Company Name (if applicable) _________________________________________

Date of Birth Month
Monthn Dept. n Suite n Apt. n Post Office Box n Private Mailbox ____________

Daytime Phone (required) __________________________________

Street Address ___________________________________________________

Cell Phone (required) _____________________________________
Preferred E-mail Address ________________________________

City ______________________ State/Province____ ZIP/Postal Code___________(Required for immediate access to online member benefits, including journals)

Country ____________________________ Mailing Address: n Home n Office(For account authorization and deliverability purposes.)n Please check here if you wish to be excluded from non–ACP-related mailings

Other surname used professionally ____________________________

Recovery E-mail Address _________________________________(To assist in verifying information)

Education/Training Information (Required):n I have graduated from a medical school listed in the World Directory of Medical Schools: www.wdoms.org.
Name of Medical SchoolCity

State/ProvinceCountry

Year GraduatedDegree Earned

Resident/Fellow Membership is limited to physicians accepted into accredited residency training programs in internal m­ edicine,combined internal medicine programs, neurology, or fellowships in a subspecialty of internal medicine.
Present Position
Example: Resident

Year of Residency Training
Example: Training Year 1

Training End Date
Example: 06/2022

Print Name of Program Director _______________________________________ Program E-mail Address _____________________________________
Graduate Medical Education (Indicate current training program)
Name of Institution

City

State/ProvinceCountry

End Date

Residency
Fellowship
Certification Status: If certified, please attach a copy of the certificate and indicate the following:___________________________________________________________________ Date certified: _______________________________________
Full name of certification (if applicable)

Month/year and expiration date

Applicants outside ACP Chapters must be sponsored by a current ACP MACP* or FACP who must submit a brief description of the applicant’s training program. If a current FACP or MACP*
cannot be located in the area, a Program Director may serve as the sponsor. Please visit www.acponline.org/intjoin to obtain a copy of the sponsorship form. For a list of ACP International
Chapters, please visit www.acponline.org/chapters.
Print name of ACP MACP* or FACP _______________________________________________________E-mail _______________________________________________ (ifDemographic Information
Do you identify as Latinx, Latino, Latina or Hispanic?
n Yes n No n Prefer not to answer
Do you identify as Middle Eastern or North African?
n Yes n No n Prefer not to answer

With what racial group(s) do you identify? Please
select all that apply.
n Amer Indian, Native Amer, Indigenous or AK Nativen Asian, Asian American or Pan Asiann Black, African American or Afro-Caribbeann Native Hawaiian or Pacific Islandern Whiten Prefer to specify: __________________________n Prefer not to answer

What is your gender?
n Woman n Man n Genderqueern Non-Binary/Third Gendern Prefer to self-describe: ______________________n Prefer not to answer
Do you identify as Transgender?
n Yes n No n Prefer not to answer

SIGNATURE OF APPLICANT: I affirm that I have not been the subject of disciplinary action**. I have read the ACP Pledge (www.acponline.org/acppledge) and affirm
that I will uphold the ethics of medicine, as exemplified by the standards and traditions of the College.
**If you have been subject to disciplinary action, please attach a detailed explanation, including current status, of any issue(s).

Sign Here

Signature of Applicant (Required)

Date

PLEASE DO NOT DETACH.

PAYMENT REQUIRED WITH APPLICATION

Send application with payment to: American College of Physicians, Member
Credentialing, 190 N. Independence Mall West, Philadelphia, PA 19106-1572 USA,or fax to +1-215-351-2799.
All dues quoted are for the membership year July 1, 2024–June 30, 2025.
Dues: $49 USD

ACP USE ONLY

Amount Paid $49 USD

n Check enclosed. Must make payable to ACP, and remit in U.S. funds

drawn on a U.S. bank.

n Charge dues to:

Card # __________________________________________________
Month / _________
Year
Exp. Date _______
Security Code ____________________

Full Name of Applicant (Please Print)

Reset Form

Signature___________________________________________
RequiredAS3018-5

International Resident/Fellow
Member Application

Resident/Fellow Member Application
International Only
What is ACP Resident/Fellow Membership?

How long is the term?

Resident/Fellow Membership is a temporary category of membershipin ACP with all privileges except the right to hold office or to sponsor
candidates for membership. Resident/Fellow Members in good standing after two years of membership have the right to vote. Resident/
Fellow Membership is generally limited to physicians in approvedresidencies in internal medicine, combined internal ­medicine
programs, neurology, or to physicians in fellowships in subspecialties
of internal medicine.

As long as dues are kept current, the Resident/Fellow Member term isgenerally for the duration of postgraduate years after medical school
training is completed. As the term of Resident/Fellow Membershipdraws to a close, you will be contacted about becoming a full Member.

How do I become a Resident/Fellow Member?
A signed application that meets the criteria for Resident/FellowMembership, along with the appropriate dues payment, is required
prior to election.
The ACP Governor in chapter countries will be informed of applications
received from these countries. For a list of ACP International Chapters,
please visit www.acponline.org/chapters. In ­countries where there is
no ACP Chapter, the applicant must be sponsored by an ACP MACP* orFACP. If an ACP MACP* or FACP ­cannot be located, the Program Directoror Chair of Medicine at the ­training institution may act as asponsor for the applicant. To obtain a copy of the sponsorship form,
please visit www.acponline.org/intjoin.
When do I apply?
As soon as you have been accepted into an approved postgraduate
training program in internal medicine, combined internal medicine program, neurology, or a fellowship in a subspecialty of internal medicine.
Membership Dues Information
A dues payment must be submitted with your application. Please
include a full year’s dues payment. Please see the front of the­application for current dues information.
A credit of the unused portion will be applied to your next year’s dues.
All ACP dues are subject to change annually.
Applicants not elected may obtain a full refund or credit. Member­discounts not valid on previously purchased items. Membership benefits will begin once the dues payment has been processed.

About ACP Membership
Membership in ACP includes membership in your local ACP country/
regional chapter, if applicable, and ACP Services. A portion of your dues
supports ACP national and ACP Services. Members may not opt out of
any of these entities.
• ACP provides education, information, and publications in support ofits mission—To enhance the quality and effectiveness of health careby fostering excellence and professionalism in the practice of medicine. To learn more about ACP activities, visit www.acponline.org.
• ACP country/regional chapter structure allows the College to provide
programming and networking to members that reflects the needsof local physicians. Visit www.acponline.org/chapters to learn more.
• A CP members are offered the exclusive benefit of access to “MemberConnection.” This is an online directory of ACP members (unlessthey ask not to be included) that is accessible to members only.
Please visit www.acponline.org/dues to learn how dues areapportioned to each entity.
ACP Ethics Statement
ACP members are expected to uphold the ethics of medicine ase­ xemplified by the standards and traditions of ACP, including thosein the Ethics Manual (www.acponline.org/ethicsmanual). A booklet version can be ordered through Member and Product Support.
Members should also be familiar with the College’s current procedures for addressing ethical complaints against ACP members(www.acponline.org/complaintsprocedures). The staff of ACP’sCenter for Ethics and Professionalism is available as a resourcefor questions concerning ethics.

How to Apply for Resident/Fellow Membership

2. ACP Chapter Review

1. Materials to be submitted:	The ACP Governor in chapter countries will be informed of applications
received from these countries. For a list of ACP Chapters, please visit
www.acponline.org/chapters.

• Application form. Fully completed and signed.
• Dues payment. (Please note, dues will be prorated based uponmonth of election, for new resident/fellow members. Any unused
portion of the dues will be applied to next year’s dues).
• Applicants living outside of an ACP Chapter must provide asponsorship form (may be found at www.acponline.org/intjoin
and sent under separate cover).	Mail this application and any required documentation, alongwith dues payment, to ACP at the address found in the Contact
Information section of this application. Notification of election
may take up to six weeks. If an applicant does not fulfill the ­necessary
requirements, the ACP Governor and/or ACP Credentials Committee
may request additional information. Applicants not elected within six
months of submission must submit a new ­application and supporting
documentation.

3. Applicants outside ACP Chapters	Applicants outside ACP Chapters must be sponsored by a ­current
ACP MACP* or FACP. If a current FACP or MACP* cannot be locatedin the area, a Program Director may serve as the sponsor, which­confirms enrollment of the applicant. Sponsors must provide a brief
description of the applicant’s training program, either by letter/email to the ACP or by completing the International Resident/Fellow
Member Sponsorship form available at www.acponline.org/intjoin.
This description may be submitted separately from the application.
*MACP: Recipient of Mastership.

For Assistance, Call +1-215-351-2600 or 800-227-1915 in the U.S. or Canada(M–F, 9 a.m.–5 p.m. ET)
E-mail: help@acponline.org
Send Application, Dues Payment, and Supporting Documentation:
ACP, Member Credentialing, 190 N. Independence Mall West, Philadelphia, PA 19106-1572 USA
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