Medical Student Membership Application

IMPORTANT NOTE:

A medical student attending an AAMIC or CAMCS (CAMCE) accredited medical school may apply to become a Student Member. An Active Member or Emeritus Member shall verify the applicant's role in their training or research by completing a reference, once the application is submitted. An individual is eligible for the category of Student Member for the duration of their medical school.

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.

I am a medical student attending (please select one): *

An American Association of Medical Colleges (AAMC) accredited medical school A Committee on Accreditation of Canadian Medical Schools (CAMCS or CAMCE) accredited medical school A Commission on Osteopathic College Accreditation (COCA) accredited medical school

Professional Information & References

College / University *

Start Date *

End Date *

College / University

Start Date

End Date

Medical or Osteopathic School *

Start Date *

End Date *

Reference *

Reference Email Address *

(MUST be an ACTIVE 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.