ACP Resident/Fellow Membership Reinstatement Request

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Contact Information

ACP ID

Date of Birth

First Name

Middle Initial

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Fax Number

E-mail

Residency Information

Name of Training Institution

Institution Type

Residency

Fellowship

Specialty Type

City/Town

State/Province

Expected Completion Month

Expected Completion Year

Annual Dues

To Ensure Membership through June 30, 2023 [i]

Amount paid for dues [ii]

$130.00

[i] Membership dues rates are pro-rated throughout the membership year. The dues you are charged will be contingent upon the month you reinstate. [ii] Physicians outside of the United States should contact ACP Member and Product Support for reinstatement rate options.

Agreement

I affirm that I have not been the subject of disciplinary action* and that information provided on this application is true and complete and I authorize ACP to obtain updated information from my training program for verification

*If you have been subject to disciplinary action, please contact Member Credentialing at 800-227-1915, or 215-351-2600 or by email at help@acponline.org.

Payment Details

Once 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 ACP Member and Product Support (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.