Application for Membership

The following information is submitted for consideration for membership in the American College of Medical Quality. Any physician or non-physician health care professional with an interest in, or with full or part-time responsibilities in quality, utilization or risk management; quality assurance or improvement; utilization review, or other branches of the specialty is eligible for acceptance. Any student, resident or fellow with an interest in, or planning a career in medical quality management or clinical quality improvement, is also eligible for acceptance.

I am applying for   Physician membership      (must be an MD, DO, DMD, DDS, DPM or other health-related doctorate)      Annual dues:        $145 for the first year (includes application and processing fee)        $295 for subsequent years ($330 if paid after 12/31) Affiliate membership      (residents, students and all health care professionals not eligible for physician membership)      Annual dues:        $80 for the first year (includes application and processing fee)        $125 for subsequent years ($135 if paid after 12/31) Resident or Fellow membership      Annual Dues:        $35 annual membership fee, first year dues payable upon application Student membership      Dues:        $25 one time membership fee        students can join at any time while in medical school
COMPLETE THE ENTIRE APPLICATION. You will need to include a copy of your professional license (if applicable) by uploading a PDF copy of it as instructed below. a copy of your current curriculum vitae or resume (short version, five pages maximum) by uploading a PDF copy of it as instructed below. your Visa or MasterCard information where indicated in the form below.
*First Year Dues Amount
*Credit Card Number
*Expiration Date	1 2 3 4 5 6 7 8 9 10 11 12 2010 2011 2012 2013 2014 2015      *Security Code
Name on Card if different from applicant name
*Applicant First Name
*Applicant Last Name
Degree(s)
Job Title (if applicable)
*Institution/Employer
*Street Address (work or school)
*City
*State	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY     *Postal Code
*Country
Street Address (home)
City
State	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY     Postal Code
Country
*At which address would you like to receive your ACMQ mail?	Work / School       Home
*E-mail Address
*Phone
Fax
Medical School
Year Graduated (or expected to graduate/complete)
Medical Education Number (if applicable)
Residency Program (if applicable)
Residency Completion Date (if applicable)
Primary Specialty
Board Certified?	Yes       No     Year
*In which professional area(s) do you work? Check all that apply:   Clinical practice (hospital)       Clinical practice (group or solo)   Management/executive (hospital)      Management/executive (health plan)   Management/executive (disease management)   QIO/government       Academic (teaching)       Academic (research)   Corporate/industry       Consulting       Military       Student
*Memberships in professional societies - check all that apply:   AMA       AOA       ANA      ADA       ACPE   Other     None
*Reference (name)
*Reference's Phone Number
Upload a PDF of your current curriculum vitae or resume (short version, five pages maximum) by selecting a file to upload. ALSO Upload a PDF of your professional license (if applicable)
*Required field
Uploading files may take a few moments. Please click the Submit Form button only once.