Practicing DPM Membership Application Form

Thank you for your interest in APMA! We look forward to being of service. Please complete the form below to begin the application process

CONTACT INFORMATION
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    (changed due to marriage, divorce, etc.)
 
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    APMA does not share cell phone or email addresses.
 
 
    Month, Day, Year (For statistical purposes, only.)
 
    For statistical purposes, only.
 
    For statistical purposes, only.
 
    For statistical purposes, only.
 
 
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    If yes, please provide additional information via email at apply@apma.org. These will be included in the online "Find a Podiatrist" directory.
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    Select the option that most closely describes your primary practice arrangement.
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    All APMA-related correspondence will be sent to this address. APMA does not share email addresses.
EDUCATION
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    (PMS36, etc.)
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    Month and Year
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    Month and Year
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    If yes, please provide additional information via email to apply@apma.org.
MILITARY
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PROFESSIONAL LICENSURE
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    Enter the Year, State, and Licence Numbers of all current licenses.
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    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.
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    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.
CERTIFICATIONS AND MEMBERSHIPS
   
   
   
   
   
   
   
   
   
   
   
AGREEMENT
   
  Membership for those employed by the Veteran's Administration or on active military duty will automatically be aligned with the Federal Service component. If you are V.A. employee or on active duty military, and you want to be aligned with your local state component, please check the box above.
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    If you are a prior member, please indicate the state in which you practiced at the time.
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    Please enter the colleague's name or "N/A" if not applicable.
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  By checking the box above, I agree to uphold and abide to the purposes, bylaws, code of ethics, and all rules and regulations of my component association and the APMA. I understand that no one has an automatic right to be elected to membership in this voluntary organization. I understand that I may be required to provide additional documentation (copy of all state licenses, business card, sample of stationery, etc.) to my component society. I understand that dual membership (state component and national association) is required to be a member in good standing. I agree not to represent myself as a member of APMA or my component if, for any reason, I cease to be a member in good standing. I agree that incomplete or false information may be grounds for denial or termination of membership. I understand that APMA dues may be tax deductible as a business expense; however, they are not deductible as a charitable contribution for federal tax purposes.
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    Month, Day, Year

Required = required information