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Items in red are required.

First Name

Middle Name

Last Name

Suffix 

(MD, etc)

Mailing Address

City

State

Postal Code

Country   
   

Office Phone

FAX

Home Phone

Email Address

   

Specialty

Medical School

School's Country

Other International
Medical Organizations

 

Membership Details

Please check the appropriate type of membership.

  Description Price ($US)
REGULAR FELLOWS - Annual Dues $  175
ASSOCIATE FELLOWS - Annual Dues $  50
AFFILIATE FELLOWS - Annual Dues $  25
STUDENT FELLOWS - Annual Dues $  25

As required to process any chosen fellowship category: Please send your RESUME' and CURRICULUM VITAE together with copy of your Medical diploma and enclose your chosen fellowship fee for processing.


 Make checks payable to:
American College of International Physicians

 

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