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ARE REQUIRED FIELDS
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Name:
First / Middle Initial / Last
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Choose a Password:
Title:
Credentials:
Program Type:
Community Based
Community Based and Medical School Administered
Community Based and Medical School Affiliated
Medical School Based
Military Program
Unknown / NA
Organization:
Years in Healthcare:
Years in Current Position:
Years in Family Medicine Administration:
Address1:
Address2:
City / State / ZIP+4:
Click to Look-Up Zip+4
AL = ALABAMA
AK = ALASKA
AS = AMERICAN SAMOA
AZ = ARIZONA
AR = ARKANSAS
CA = CALIFORNIA
CO = COLORADO
CT = CONNECTICUT
DE = DELAWARE
DC = DISTRICT OF COLUMBIA
FM = FEDERATED STATES OF MICRONESIA
FL = FLORIDA
GA = GEORGIA
GU = GUAM
HI = HAWAII
ID = IDAHO
IL = ILLINOIS
IN = INDIANA
IA = IOWA
KS = KANSAS
KY = KENTUCKY
LA = LOUISIANA
ME = MAINE
MH = MARSHALL ISLANDS
MD = MARYLAND
MA = MASSACHUSETTS
MI = MICHIGAN
MN = MINNESOTA
MS = MISSISSIPPI
MO = MISSOURI
MT = MONTANA
NE = NEBRASKA
NV = NEVADA
NH = NEW HAMPSHIRE
NJ = NEW JERSEY
NM = NEW MEXICO
NY = NEW YORK
NC = NORTH CAROLINA
ND = NORTH DAKOTA
MP = NORTHERN MARIANA ISLANDS
OH = OHIO
OK = OKLAHOMA
OR = OREGON
PW = PALAU
PA = PENNSYLVANIA
PR = PUERTO RICO
RI = RHODE ISLAND
SC = SOUTH CAROLINA
SD = SOUTH DAKOTA
TN = TENNESSEE
TX = TEXAS
UT = UTAH
VT = VERMONT
VI = VIRGIN ISLANDS
VA = VIRGINIA
WA = WASHINGTON
WV = WEST VIRGINIA
WI = WISCONSIN
WY = WYOMING
XX = XXXXX
Phone:
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FAX:
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E-Mail:
Affiliation:
from Reprint 135-B ACGME Accredited Residency Programs in Family Practice
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Or
from Reprint 134 Activity in Family Medicine
ACGME #:
I wish to become a member of AFMA. I understand that I will be directed to a new page to pay my dues of $150 with PayPal.