For Current ACP Members

To apply for Fellowship:
1. Complete 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.
3. Please note the following requirements to apply for Advancement to Fellowship:• Member must be 3 years post residency training.
• Member must have 3 prior years of paid membership in the College.

Applicant Contact Information
Last

Applicant’s ACP # (if known)
First

Code:

MIDate of Birth MonthMonth

Company Name (if applicable)
Dept.

SuiteApt.

Post Office BoxPrivate Mailbox ____________

DayDayYearYear

Daytime Phone_
Cell Phone_

Street Address

Preferred E-mail Address _City

StateCountry

Mailing Address:(Required for immediate access to online member benefits, including journals)

ZIP +4
HomeOffice

National Provider Identifier (NPI)(Provide your individual 10-digit NPI number. For U.S. applicants only.)

Please check here if you wish to be excluded from non–ACP-related mailings.
(To assist in verifying information)

Education and Training
Self-designated Specialties: Please indicate as your “primary” specialty/subspecialty the areain which you spend most of your time. As your “secondary” specialty/subspecialty, indicate the one
in which you spend the next most amount of time (if applicable). Use codes on reverse.

Primary
Secondary

Board Certification: Please list all board certifications. Candidates must attach proof of board certification for all boards except ABIM and its subspecialties.
Name of Board

Candidate #Date Certified

Expiration Date

Date Recertified

Expiration Date

Documentation of Professional Activities
Please note: Please select from the list below all of the professional activities you wish to have considered in determining your eligibility for Fellowship.
For each item selected, please provide sufficient detail in your curriculum vitae or in a separate document to assist in determining whether the activity
meets the standard for Fellowship.
Current Members must have a minimum of three years of membership in good standing post-training to advance to Fellowship.
Publications: Applicants who wish to have their publications included indetermining eligibility must include a bibliography of published articles since
the completion of training. Peer-reviewed journals are given more weight.
Continuing Medical Education (CME): Candidates must select one of thefollowing. Applicants do not need to provide additional documentation at thistime though may be required to later.
I have completed a total of _________ CME hours over the past three years.
I have not earned CME hours over the past three years.
Additional Educational Activities:
Subspecialty certification
Recertification
Advanced degrees
Certificates of special competence
Participation	in the Medical Knowledge Self-Assessment Program® (MKSAP)
for CME credit
Other __________________________________________________
Teaching Activities:
Community hospital
Institutional

Office-based
Other _____________________________

Leadership Activities: Please select those where you are actively influencing
the outcomes within your professional work setting or community:
Medical director
Committee chair
Committee participant
Health advocacy
Quality improvement initiatives
Medical volunteerism
Nonmedical volunteerism
Other __________________________________________________ACP Activities: If you have been involved in a local or national ACP-related­activity, please note below:
Attendee of an ACP meeting or course
Faculty at an ACP meeting or course
ACP committee member
Other _________________________________________________
Please visit www.acponline.org/facp for information on additional professional­activities.
Both sides of application must be completed.

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 215-351-2799.

ACP USE ONLY

Initiation Fee: $175

Check enclosed. Must make payable to ACP,
and remit in U.S. funds drawn on a U.S. bank.
Charge dues to:

Card #
Exp. Date ______________ Security Code _____________________
Month / Year
Full Name of Applicant (Please Print)

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Signature____________________________________________
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Application for Advancement to Fellowship

Sponsors
All candidates submitting an application must identify two sponsors who are current MACPs or FACPs from the same ACP chapter as the candidate. The current
ACP Governor for the candidate’s chapter/region or a member of the candidate’s family may not act as sponsors. Please visit www.acponline.org/facp to locate
sponsors in your area. If you do not know the sponsor professionally, please provide them with a copy of your curriculum vitae.
Sponsor #1 Name: ___________________________________________

E-mail: ___________________________________________

Sponsor #2 Name: ___________________________________________

E-mail: ___________________________________________

Ethics Statement
ACP members are expected to uphold the ethics of medicine as exemplified by the standards and traditions of ACP, including those in the Ethics Manual(www.acponline.org/ethicsmanual). A booklet version can be ordered through Member and Product Support. 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 forEthics and Professionalism is available as a resource for questions concerning ethics.
SIGNATURE OF APPLICANT: I affirm that all medical licenses granted to me are active and current and that I have not been the subject of disciplinary
action.* I understand that, in order to evaluate my application, ACP will review my credentials. I agree to cooperate in such a review and allow
others to provide information regarding my credentials. To the best of my knowledge, all information furnished by me in this application and in thesupporting documentation is true and complete. 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.
*C heck here if your medical license is not in good standing, or if you have been subject to disciplinary action, and attach a detailed explanation, including current
status, of any issue(s).

Sign Here

Signature of Applicant (Required)

Date

Materials Required to Complete the Fellowship Application Process
Applications will not be considered until all materials are submitted and complete. After six months, applications with missing information or documentation will beremoved from consideration and the applicant will be required to resubmit all materials. Sample forms and materials are at www.acponline.org/FACP. Please use thelist below as a reference for the materials that must be submitted for Fellowship.
Application Form, completed and signed. Please retain a copy for your records.	Fellowship Application Fee, enclosed with application. Please note: Membership dues must be current. If dues are outstanding for the current membershipyear, please visit www.acponline.org/dues to make a payment prior to submitting this application.
Current Curriculum Vitae: There should be no gaps from medical school graduation. Append additional documentation as appropriate.
Bibliography if you wish to have published works considered for Fellowship eligibility.
Proof of Board Certification(s) for all boards except for ABIM and its subspecialties.	Sponsorship Letters or Forms: You or your sponsors may submit the letters/forms along with this application by fax 215-351-2799 or by e-mailat FACP@acponline.org.

Submission Information and Schedule
You will be sent an acknowledgment after receipt of your application. If an applicant does not fulfill requirements, the ACP Governor and/or the Credentials
Committee may request additional information. Incomplete applications will be withdrawn six months after the initial submission. Applicants not elected within six
months of submission must submit a new application and supporting documentation.
Applications which are complete and accompanied by all required fees and supporting documentation will be considered for the next election upon completion of thereview process. Generally, the review process takes approximately four months before the election is finalized. Some applications may require review at a Credentials
Committee meeting, traditionally held in May and November.

Notification of Election
The Credentials Committee approves and formally “elects” Fellowship candidates on behalf of the Board of Regents and with their input. Candidates are officiallynotified of their election or the deferral of their application in writing. Fellowship elections are held in July, September, November, January, and March of each year.
Please keep a copy of your application for your records.
SELF-DESIGNATED SPECIALTY/SUBSPECIALTY CODES
IM
ADL
AI
CCM
CDEND
GE
GER

General Internal Medicine
Adolescent Medicine
Allergy and Immunology
Critical Care Medicine
Cardiovascular Disease
Endocrinology, Diabetes, and Metabolism
Gastroenterology
Geriatric Medicine

HEM
HEO
HM
HPM
ID
ON
MPD
N

Hematology
Hematology/Oncology
Hospital Medicine (Hospitalist)
Hospice & Palliative Medicine
Infectious Disease
Medical Oncology
Medicine-Pediatrics
Neurology

NEP
PUD
RHU
SLEEPSPORTOS

Nephrology
Pulmonary DiseaseRheumatology
Sleep Medicine
Sports Medicine
OtherApplicant Please Note: The following information will help provide ACP with accurate membership statistical data but will not be considered in connection with yourapplication for membership. Completion is optional.
GenderMaleFemale
Elect not to specify

Ethnicity:
White, not of Hispanic origin (1)African/African American (2)Asian/Asian American (3)Arab (4)Hispanic (5)Indian (I)Pakistani (P)Native American/Alaskan Native (7)Pacific Islander (8)Other (9)Elect not to specify (E)For Assistance, Call 215-351-2704 or 800-227-1915 in United States or Canada(M–F, 9 a.m–5 p.m. ET)
E-mail: help@acponline.org
Send Application and Dues Payment:
ACP, Member Credentialing, 190 N. Independence Mall West, Philadelphia, PA 19106-1572, USA

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