Podiatric Resident 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 AS A POSTGRADUATE MEMBER

Please complete this application in full.

Last Name *

First Name *

Middle

Previous Last Name (changed due to marriage, divorce, etc.)

Nickname

Home Address *

City *

State *

Zip Code *

Cell Phone *

Home Email *

EDUCATION

Check College *
Choose 1

Year of Graduation *

Postgraduate Training *
Choose up to 3

Fellowship

Residency

I did not place in a postgraduate training program, but I still would like membership at no fee

Other

Postgraduate Program Name *

Program Address *

Program City *

Program State *

Program Zip Code *

Program Office Fax Number

Program Office Phone Number

Program Office Email

Program Type (PMS36, etc.) *

Program Begin Date *

Projected Completion Date *

Applicant Signature

Date *