Podiatric Physician Application for Membership

I hereby apply for membership in the Florida Podiatric Medical Association (FPMA) and the American Podiatric Medical Association (APMA). If elected, I agree to uphold and abide by the purposes, bylaws, code of ethics, and all rules and regulations of the FPMA and the APMA. I understand that no one has an automatic right to be elected to membership in this voluntary organization.

APPLICATION FOR MEMBERSHIP

Please complete this application in full.


Choose 1

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Principal Office/Residency Address
Home Address
Office Administrator
Second Office Address

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EDUCATION

Undergraduate Degree
Graduate Degree
Podiatric Medical Degree
Postgraduate Education


Yes
No
If yes, complete the section below.

MILITARY


Choose 1


Yes
No

PROFESSIONAL LICENSURE

Podiatric Medical Licenses


Yes
No


Yes
No

PODIATRIC MEDICAL PRACTICE   

Original Practice Start Date

APMA RECOGNIZED ORGANIZATIONS

(Check only those in which you have certification/membership)

Choose up to 2

Choose up to 11


Yes
No


Yes
No

SIGNATURE/INSTRUCTIONS

Please be aware that you may be required to provide additional documentation (copy of all state licenses, business card, sample of stationery, etc.) to FPMA.

I understand that dual membership (FPMA and APMA) is required to be a member in good standing. I agree not to represent myself as a member of the FPMA or the APMA, if for any reason I cease to be a member in good standing. I also understand that a portion of my annual dues is in payment for a one-year subscription for the APMA News and for the Journal of the American Podiatric Medical Association. I agree that incomplete or false information may be grounds for denial or termination of membership.

FPMA dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense.