Join RIAFP Complete the form below to become a new RIAFP member. Participant Information Your contact information First Name Last Name Business Address Business City Business State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMinor Outlying IslandsMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Business Zip Code Business Phone Business Email Home Address Home City Home State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMinor Outlying IslandsMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Home ZIP Code Home Phone Home Email Date of Birth Place of Birth Training Information Your education and training history Undergraduate 1 Undergraduate 1 - Date Began Undergraduate 1 - Date Ended Undergraduate 2 Undergraduate 2 - Date Began Undergraduate 2 - Date Ended Medical School 1 Medical School 1 - Date Began Medical School 1 - Date Ended Medical School 2 Medical School 2 - Date Began Medical School 2 - Date Ended Internship Hospital Internship - Date Began Internship - Date Ended Residency Hospital Residency - Date Began Residency - Date Ended Assistant Hospital Assistant - Date Began Assistant - Date Ended Post-graduate Study 1 Post-graduate Study 1 Location Post-graduate Study 1 - Date Began Post-graduate Study 1 - Date Ended Post-graduate Study 2 Post-graduate Study 2 Location Post-graduate Study 2 - Date Began Post-graduate Study 2 - Date Ended Career Information Your current career positions and locations Date Began Practice Staff/Teaching - Hospital 1 Hospital 1 Position Staff/Teaching - Hospital 2 Hospital 2 Position Staff/Teaching - Hospital 3 Hospital 3 Position AMA Member Member of the American Medical Association (AMA)? AAFP Member Member of the American Academy of Family Physicians (AFP)? Medical Societies Of what other medical societies are you a member? Personal Information This information will remain confidential Medical Organization Refusals Have you ever applied to join a medical organization and been refused membership? Please explain. Professional/Personal Problems Are there any professional or personal problems that could disqualify you from membership? Please explain. Mailing List Subscribe to RIAFP newsletters and announcements? Resend private link?