Please remember to print a copy of this form for your records. * Required field Name * ACP ID # * Address * City * State/Province Zip/Postal Country - None -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 SaharaYemenZambiaZimbabwe Contact Number * E-mail * Please indicate the type of dues adjustment being requested: Dues Adjustment Type: * Disability (Permanent/temporary adjustment) I have a medical condition that seriously interferes with the ability to practice medicine and/or earn income. Financial Hardship (Temporary adjustment, with publications) I am experiencing a sudden, unforeseen short-term financial difficulty resulting in substantial reduction of income. RETIREE/SEMI-RETIRED – All criteria must be met to be eligible (A permanent adjustment, no renewal required) Part Time (Temporary reduction only, renewable annually upon request) I am under age 60, and have retired early, or are , unemployed, or working 20 hours or less per week. Condition Type * Permanent condition (personal physician’s note required) Temporary condition (temporary reduction only, renewable annually upon request) clear Medical condition * Impact on employment * Anticipated date of return to employment * Employment Type * Full time Part time Dues Type * Dues reduction (with publications) Please describe the circumstances for requesting this adjustment and how long and to what degree this will affect your ability to pay dues * Dues Type * I am age 60 or older, have been a member of the College for ten or more years and am working 20 or fewer hours per week or fully retired. I am age 75 or older, have been a member of the College for 30 or more years, and am working 20 or fewer hours per week or fully retired. Dues adjustments are generally temporary and renewable once, depending on the individual’s circumstances, and do not affect membership status or benefits unless otherwise noted. You may be asked to provide additional information and/or documentation. Information provided will be considered confidential. Please allow up to four weeks for review and notification of decision. Questions: Contact us (M–F, 9 a.m.–5 p.m. ET) 800-ACP-1915 (800-227-1915), or direct at 215-351-2600.