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Thank you for becoming a member of the California Podiatric Medical Association. Please complete all fields below to submit your application. For more information on Association dues, please contact Jeannette F. Steed at CPMA at (800) 794-8988 or e-mail jsteed@calpma.org. If emailing for dues information, please include your full name and original start of practice date. If you are applying for resident membership, please do not use this form for application. Resident members should contact APMA directly at (800) 275-2762 for membership application and dues information. Again, thank you for becoming a member of the California Podiatric Medical Association, we look forward to working with you!

CPMA Membership Application

Fields marked with * are required.

Personal Information

First Name*

Middle Initial

Last Name*

Previous Last Name

If changed due to marriage, divorce, etc.

Sex*

Male Female

Date of Birth*

Please enter a date, MM/DD/YYYY, e.g., 6/17/1956.

Social Security Number (Optional)

Spouse's Name

Ethnicity

For demographic use only.

White African American Hispanic
American Indian Asian/Pacific
Other

US Citizen

Yes No

Contact Information

Home Address*

Your home address is essential for identifying and contacting your federal and state legislators.

City*

State*

Zip*

Home Phone (###) ###-####

Please include area code.

Home Fax (###) ###-####

Please include area code.

E-Mail Address

CPMA and APMA communicate many important issues via e-mail, including membership information. Please be aware that your e-mail will NOT be shared with outside vendors.

Offices (Up to Three)

Office #1

Practice Name*

Principal Office Address*

Please include unit or suite number if applicable.

City*

State*

Zip*

Office Phone* (###) ###-####

Please include area code.

Office Fax* (###) ###-####

Please include area code.

Office #2

Practice Name

Second Office Address

Please include unit or suite number if applicable.

City

State

Zip

Office Phone (###) ###-####

Please include area code.

Office Fax (###) ###-####

Please include area code.

Office #3

Practice Name

Third Office Address

Please include unit or suite number if applicable.

City

State

Zip

Office Phone (###) ###-####

Please include area code.

Office Fax (###) ###-####

Please include area code.

Education

Undergraduate Degree
Year YYYY	State Abbrev	Institution	Degree

Graduate Degree
Year YYYY	State Abbrev	Institution	Degree

Postgraduate Education*

If you have more than two fellowships or residencies, please include in the comments field below.

Yes (If yes, complete this section) No

Postgraduate Education #1

Fellowship
Residency:

Rotating Podiatric Residency (RPR)
Podiatric Orthopedic Residency (POR)
Primary Podiatric Medical Residency (PPMR)
Primary Surgical Residency (PSR)
Podiatric Medicine and Surgery Residency (PM+S)

Begin Date MM/YY

State Abbrev

Institution

Completion Date MM/YY

Postgraduate Education #2

Fellowship
Residency:

Rotating Podiatric Residency (RPR)
Podiatric Orthopedic Residency (POR)
Primary Podiatric Medical Residency (PPMR)
Primary Surgical Residency (PSR)
Podiatric Medicine and Surgery Residency (PM+S)

Begin Date MM/YY

State Abbrev

Institution

Completion Date MM/YY

Military Service

Check any that apply:

USA USAF USN USMC USCG
Other

Begin Date MM/YY

Date Separated MM/YY

Current Rank

Reserves

If in Reserves, branch of service:

Professional Licensure

Podiatric Medical Licenses

Year* YYYY	State* Abbrev	Number* E-####
Year	State	Number
Year	State	Number

Podiatric Medical Practice

Original Practice Start Date* MM/DD/YYYY

Have you ever had a license to practice podiatric medicine suspended or revoked in any state?*

If yes, please explain in comments section below.

Yes No

Are you currently, or have you ever been on probation, suspension or investigation by any licensure authority, state or federal agency?*

If yes, please explain in comments section below.

Yes No

Previous member of APMA*

If yes, please explain in comments section below.

Yes No

Dates YY-YY

Component Association

Comments

Please include any answers to the above questions that require explanation. Here you may also include the name of the member who recruited you.

Signature*

By initialing here, I understand that after submitting this application, I will be billed for Association dues. The membership process will not be completed until dues payment is received and entered by CPMA. CPMA will inform APMA and my local society of my activated membership.

Initials:

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CPMA Membership Application

Offices (Up to Three)