* Required field Contact Information ACP ID Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 First Name * Middle Initial Last Name * Address 1 * Address 2 City * State/Province * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Other)Armed Forces AmericasArmed Forces PacificCaliforniaCanal ZoneColoradoConnecticutDelawareDistrict of ColumbiaFed. States Of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPacific IslandsPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanYukonOther Zip/Postal Code * Country * - Select -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Phone Number * Fax Number E-mail * Recruiting Information If an ACP member recruited you, please list his/her name: Recruiting member ACP ID (if known) Annual DuesTo Ensure Membership through June 30, 2022 [i] Priority Code Priority codes allow us to administer special offers, discounts, and help us determine which of our products and services are of most value to you. Priority codes are listed on ACP print promotions and some electronic promotions. The priority code is indicated clearly within written text or on the mailing panels of most forms near the ordering information. Entering a priority code will help us meet your future needs. Payment Code Members and Fellows - United States [ii] * Eight or fewer years out of medical school Nine or more years out of medical school Dues Amount * $ [i] Membership dues rates are pro-rated throughout the membership year. The dues you are charged will be contingent upon the month you reinstate. The allocation of chapter dues is waived for newly reinstated members. Upon membership renewal, annual dues will include fees to support both the national ACP and your local chapter. For the renewal dues rate in your chapter, please visit https://www.acponline.org/dues. [ii] Physicians outside of the United States should contact ACP Member and Product Support for reinstatement rate options. Agreement Agreement I affirm that all medical licenses granted to me are in good standing, and that I have not been the subject of disciplinary action.* I understand that, in order to evaluate my request for reinstatement, ACP will review my credentials. I agree to cooperate in such a review and allow others to provide information regarding my credentials. To the best of my knowledge, all information furnished by me in this request and in any supporting documentation is true and complete. I have read the ACP Pledge and affirm that I will uphold the ethics of medicine as exemplified by the standards and traditions of the College *If you have been subject to disciplinary action, please contact Member Credentialing at 800-523-1546, extension 2704 or 215-351-2704 or by email at firstname.lastname@example.org. Payment DetailsOnce you submit this form, ACP Member and Product Support staff will contact you by email to complete your request and to process your membership dues payment. If you have any questions, please call us (M–F, 9 a.m.–5 p.m. ET) 800-ACP-1915 (800-227-1915), or direct at 215-351-2600. Member discounts not valid on previously purchased items. All ACP dues are subject to change annually. ACP's membership year runs from July 1 to the following June 30. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.