Practicing DPM Membership Application

Thank you for your interest in APMA! Completing your application is the first step toward joining the only organization fighting for podiatrists like you every day. Membership dues vary by member type and are prorated based on the APMA membership year of June 1—May 31.

CONTACT INFORMATION

	First Name
	Middle Name
	Last Name
	Previous Last Name
		(changed due to marriage, divorce, etc.)
	Home Address
	Apt. #
	City
	State
	Zip
	Cell Phone
		APMA does not share cell phone or email addresses.
	Preferred Email
		All APMA-related correspondence will be sent to this address. APMA does not share email addresses.
	Primary Office / Company Name
	Primary Office Address
	Primary Office City
	Primary Office State
	Primary Office Zip
	Primary Office Phone
	Primary Office Fax
	Primary Office Website
	Do you have more than one office location?
		If yes, please provide additional information via email at apply@apma.org. These will be included in the online "Find a Podiatrist" directory.
	Date of birth
		Please use MM/DD/YYYY format
	What YEAR did you begin practicing podiatry?
	What MONTH did you begin practicing podiatry?
	Practice Arrangement Type
		Select the option that most closely describes your primary practice arrangement.

EDUCATION

	Podiatric Medical College
	Year of Graduation
	Post Graduate Education
	Program Type
		(PMS36, etc.)
	Program Location
	Program Institution
	Date Began
		Month and Year
	Date Completed
		Month and Year
	Did you complete more than one post-grad program?
	If yes, please provide additional information via email to apply@apma.org.

PROFESSIONAL LICENSURE

	NPI Number
	Do you hold a license in more than one state?
	State Podiatric Medical License(s)
		Enter the Year, State, and Licence Numbers of all current licenses.
	License History
		Have you ever had a license to practice podiatric medicine suspended, denied, or revoked by any licensure authority? If yes, please provide an explanation via email at apply@apma.org.
	License Review
		Are you currently, or have you ever been, on probation, suspension, or investigation by any licensure authority, state, or federal agency? If yes, please provide an explanation via email at apply@apma.org.

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