International Candidate In Training Membership Application

IMPORTANT NOTE:

Candidates for membership as an International Candidate-in-Training are approved on a monthly basis by the AAPOS board of directors. References must be completed before the application is approved. International Candidate-in-Training applicants MUST be a current fellow at the time the application is submitted.

This is a time–limited membership category. An individual is eligible for the category of International Candidate-in-Training for the duration of the fellowship program plus one year for a total not to exceed three years.

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

Fellowship Director *

Fellowship Director Email Address *

(MUST be an ACTIVE, INTERNATIONAL, or EMERITUS AAPOS Member)

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.