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’s ACP # (if known)

Applicant Contact Information

Code:________________________

Last_______________________________ First_________________ MI____
Company Name (if applicable)________________________________________n Dept. n Suite n Apt. n Post Office Box n Private Mailbox ____________
Street Address___________________________________________________
City____________________________ State/Province_____ ZIP/Postal________Country____________________________ Mailing Address: n Home n Officen Please check here if you wish to be excluded from non–ACP-related mailings.
Other surname used professionally_____________________________________(To assist in verifying information)

Training/Board Status* (check choice that applies to you):n I have been certified by a recognized certifying body ininternal medicine or neurology.

Date of Birth MonthMonthDayDayYearYear

Daytime Phone (required)______________________________________
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.)n I affirm that I have successfully completed a residency in internal
medicine, a combined internal medicine program or neurology.

ORDate of Completion ________________________ (month/year)*If neither of these apply, please contact the ACP Credentialing Section at help@acponline.org before completing this application.
Applicants in Canada must be certified in internal medicine by the Royal College of Physicians and Surgeons of Canada, or the Collège des médecins du Québec.
Noncertified applicants outside of an ACP Chapter must also attach one sponsoring letter or Member Sponsorship Form from a current ACP FACP or MACP***.
Primary
Self-designated Specialties: Please indicate as your “primary” specialty/subspecialty the area in 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.

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

Secondary

Name of Medical SchoolCity

State/ProvinceCountry

Year GraduatedDegree Earned

Name of Certification/Degree/Exam

Candidate #Date Certified
Certification/Degree/
Exam

Expiration Date(if applicable)

Date Recertified(if applicable)

Expiration Date(if applicable)

Demographic 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 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 the standards 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/internationaldues for specific dues rates by country)
All dues quoted are for the membership year July 1, 2024–June 30, 2025.

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.

Amount Paid ________________________(See reverse side for dues rates)

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:
Card #__________________________________________________
MonthYear
Exp. Date _________/ _________
Security Code __________________

Full Name of Applicant (Please Print)

Reset Form

Signature___________________________________________
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International
Membership Application

Self-Designated Specialty/Subpecialty Codes
IMA
IMH
IMAH
ADL
AI
CCM
CDEND

Internal Medicine (Ambulatory)
Internal Medicine (Inpatient)/Hospitalist
Internal Medicine (Ambulatory and Inpatient)
Adolescent Medicine
Allergy and Immunology
Critical Care Medicine
Cardiovascular Disease
Endocrinology, Diabetes, and Metabolism

GE
GER
HEM
HEO
HPM
ID
ON
MPD

Gastroenterology
Geriatric Medicine
Hematology
Hematology/Oncology
Hospice & Palliative Medicine
Infectious Disease
Medical OncologyMedicine-Pediatrics

NNEP
PUD
RHU
SLEEPSPORTOSNeurology
Nephrology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
OtherInstructions

Applicants in the United States should use the domestic Membership application, accessible at www.acponline.org/join.
1. Materials to Be Submitted• The application form. The information provided must be accurate, complete, and signed.
• Applicants who are not board certified and reside outside of an ACP chapter must include a sponsoring letter or Membership Sponsoring
Form, found at www.acponline.org/intjoin, from a current ACP FACP or MACP***. If the candidate is unable to locate a current FACP orMACP***, a departmental Director (or equivalent) or Chair of Medicine may be substituted.
• Applicants certified by boards other than ABIM must provide proof of certification.
• Dues payment. (See dues rates below.)
The application form and supporting documentation, along with dues payment, should be sent to ACP, Member
Credentialing, 190 N. Independence Mall West, Philadelphia, PA 19106-1572 USA.
Notification of election is approximately four to six weeks after the application has been received.
If a Membership application does not fulfill requirements, the ACP Governor and/or the Credentials Committee may request additional information. Applicants not elected within six months of submission must submit a new application and supporting documentation.
2. About ACP Membership
Membership in ACP includes membership in ACP, your local ACP country/regional chapter, and ACP Services. A portion of your dues supports
each entity. Members may not opt out of any of these entities.
• ACP provides education, information, and publications in support of its mission—To enhance the quality and effectiveness of health care by
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 needs of
local physicians. Visit www.acponline.org/chapters to learn more.
• ACP members are offered the exclusive benefit of access to “Member Connection.” This is an online directory of ACP members (unless theyask not to be included) that is accessible to members only.
Please visit www.acponline.org/dues to learn how dues are apportioned to each entity.
3. ACP 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 for Ethics and Professionalism is available as a resource for questionsconcerning ethics.
4. Membership Dues
A dues payment must be submitted with your application. Please include a full year’s dues payment (see chart below). A credit of the unusedportion will be applied to your next year’s dues.
International Dues Rates
Membership July 1, 2024–June 30, 2025
Membership Options

Dues Rate

Membership with print publications*$350 USD

Membership with online-only access to publications$320/$165/$115** USD*Canadian residents should include the appropriate GST/HST tax if choosing the print publications option.
**This rate varies per country based on World Bank economic indicators. For dues by country, please visit www.acponline.org/internationaldues.
***MACP: Recipient of Mastership.
Applicants not elected may obtain a full refund or credit. Member discounts are not valid on previously purchased items. Membershipbenefits will begin once the dues payment has been processed.

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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