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 Information

Applicant’s ACP # (if known)

nnnnnnnn

Last________________________________ First_________________ MI____

Code:_______________________

Company Name (if applicable)________________________________________

DayYearDate of Birth Month
MonthDayYearDaytime Phone (required)______________________________________n Dept. n Suite n Apt. n Post Office Box n Private Mailbox_____________
Street Address___________________________________________________
City______________________ State /Province____ ZIP/Postal Code__________Country_____________________________ Mailing Address: n Home n Officen Please check here if you wish to be excluded from non–ACP-related mailings.

nn nn nn

Cell Phone (required)________________________________________
Preferred E-mail Address___________________________________(Required for immediate access to online member benefits, including journals)

Recovery E-mail Address____________________________________(For account authorization and deliverability purposes.)

Other surname used professionally_______________________________(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

My primary specialty is: n Family Medicine/General Practitioner n Pediatrics n Obstetrics n Gynecology n Surgery
n Other (please identify) ___________________________________________________________________________________
Demographic Information
Do you identify as Latinx, Latino, Latina or Hispanic?
n Yes n No n Prefer not to answerDo 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 and that if I am in clinical practice that all medical licenses granted to me
are active and current*. I have read the ACP Pledge (www.acponline.org/acppledge) and affirm that I will uphold the ethics of medicine, as exemplified by thestandards and traditions of the College.
*If you are in clinical practice and your medical license(s) is (are) not in good standing, or 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.
Please choose Membership option:n Full Membership with print publications: $350 USD
n Online-only Full Membership without print publications:$320/$165/$115 USD(Please visit www.acponline.org/intdues for specific dues rates by country)
All dues quoted are for the membership year July 1, 2024–June 30, 2025.

Amount Paid _______________________ACP USE ONLYn Check enclosed. Must make payable to ACP, and remit in U.S. funds
drawn on a U.S. bank.

n Chargedues to: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.
Full Name of Applicant (Please Print)

Reset Form

Card #__________________________________________________
Month / _________
Year
Exp. Date_______
Security Code____________________

Signature___________________________________________
RequiredAS3018-9InternationalPhysician Affiliate Application

­­­INSTRUCTIONS
1. Eligibility• Eligibility for ACP Physician Affiliate membership for international physicians shall include licensed physicians who graduatedmedical school from a school found in the World Directory of Medical Schools: www.wdoms.org. Further, ACP Physician
Affiliate membership is only available to physicians not trained in or practicing in internal medicine and who hold a current license
to practice in their field of medicine. Physicians trained in or practicing internal medicine should complete a full Member application
at www.acponline.org/intjoin.
• All elections are subject to review by ACP’s Credentials Committee. If an application does not fulfill requirements, the ACP Governor(if applicable) and/or the Credentials Committee may request additional information. Applicants not elected within six months of­submission must submit a new application.
• Physician Affiliate members are not eligible to vote, hold office, sit on a committee that does not have seats for nonmembers,
or attain Fellowship in ACP.
2. Materials to be submitted
Generally, the election process takes approximately two weeks providing the application is complete and includes a dues payment.
• The application form must be accurate, complete, and signed.
• Dues payment must accompany the application for the membership to be activated. Dues rates vary by country based on World Bankeconomic indicators. Please refer to the dues rate in your country of residence located at www.acponline.org/intdues. ACP’s membership year runs from July 1 through June 30 of each year. All ACP dues are subject to change at the start of each membership year. Duesare prorated for new members, and any unused portion will be applied to next year’s dues. Your dues are allocated to several specificentities: ACP, ACP Services, and your local chapter, if applicable.
3.	If there is an ACP chapter in your country, you will become a member of the chapter and, upon renewal of your ACP
membership, you will be charged chapter dues, if applicable.
4. ACP Ethics Statement	All ACP members are expected to uphold the ethics of medicine as exemplified by the standards and traditions of ACP, including thosefound in the ACP Ethics Manual (www.acponline.org/ethicsmanual). A booklet version may be ordered through Member and ProductSupport. Physician Affiliate members should be familiar with the College’s current procedures for addressing ethical complaints against
College physician members (www.acponline.org/complaintsprocedures). The staff of ACP’s Center for Ethics and Professionalism isavailable as a resource for questions concerning ethics.

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)
Fax: +1-215-351-2799
E-mail: help@acponline.org
Send Application and Dues Payment:
ACP, Member Credentialing, 190 N. Independence Mall West, Philadelphia, PA 19106-1572 USA

AS3018-9