Copy AMERICAN COLLEGE OF OSTEOPATHIC INTERNISTS, Application for Candidate Membership 11400 Rockville Pike + Suite 801_+ Rockville, MD 20852_+ 301 231-8877, PLEASE PRINT OR TYPE. Name. - AOA Preferred Mailing Address _ City. State Z1P__ Home Phone ( Work Phone (__), Fax ) Cell Phone(___). Date of Birth Email Address. _ Academic Degree Date . __ School - — FROM 0 Medical Schoo! _ . ‘Year Graduated _ Internship Institution Medicine Residency Training Institution, Date Appointed_ ' hereby cemify tha the above statements made by me are true tothe best of my knowledge and belief and that Iwill give every possible aid to the Credentials Committee 1 qualifications as a candidate. | futhermore promise that i elected to ‘candidacy in the American College of Osteopathic Internists, I will abide by the rules and regulations of the College and will endeavor to support the ethies of my profession and the good name of the American College of Osteopathic Imernists and the osteopath profession Signature of Applicant Date. | cemity thatthe above statements are true tothe best of my knowledge and belief and recommend this applicant to the Credentials Committee and to the Board of Directors ofthe American College of Osteopathie Internists For Candidate Membership. Signature of Program Director Date, Note: Return or fax this application tothe above address FOR COLI E USE ONLY: Application Received on