Candidate In Training Membership Application

IMPORTANT NOTE:

According to AAPOS Bylaws (Article V), you must apply DURING your Fellowship year to be a Candidate-in-Training AND your fellowship program MUST be AUPO FCC compliant and the applicant MUST be in a current AUPO FCC compliant clinical position. Applications received AFTER the fellowship is completed or from non-compliant programs or who are not in an AUPO FCC compliant clinical position will not be considered for Candidate-in-Training membership. Please review the Programs in Compliance list on the AUPO FCC website.

If you did not apply during your Fellowship year, please review the other membership categories to determine if you are eligible. Please note that most require practice experience. The application deadline posted on the website is firm for all except the Candidates-in-Training applications.

Please note that applicants are required to provide complete and accurate professional information and are responsible for obtaining references and verifications for credentials, licenses, certifications and educational requirements.

Personal Information

First Name & Middle Initial *

Last Name *

Credential *

Email *

PLEASE NOTE: An acknowledgement of the application will be sent by email to this address. This entry must be accurate; otherwise, no acknowledgement will be received.

Primary Office Address

Office/Clinic/Institution *

Office Street Address *

Address Line 2

City *

State *

Zip Code *

Country *

Office Phone *

Office Fax

Cell / Mobile

Please include area code / country code.

Professional Information & References

College / University *

Start Date *

End Date *

College / University

Start Date

End Date

Medical or Osteopathic School *

Start Date *

End Date *

Internship *

Start Date *

End Date *

Residency *

Start Date *

End Date *

Fellowship Training *

Start Date *

End Date *

Is this an AUPO FCC compliant clinical position under the direction of an AAPOS/AUPO approved program? *

Yes No

NOTE: Fellowship programs MUST be AUPO FCC compliant and the applicant must be in a current AUPO FCC compliant clinical position. Please review the Programs In Compliance list on the AUPO FCC website. Applications from fellows in non-compliant programs and who are not in the AUPO FCC compliant clinical position will NOT be processed.

Fellowship Director *

Fellowship Director Email Address *

Signature

I understand my responsibilities as an applicant. I have reviewed my application and have provided accurate information. *

Reenter your email *

You will have the opportunity to review and edit your form entries.