ACOFPCA Student (Free) Membership Application
Student members shall be students in colleges of osteopathic medicine accredited by The Commission on Osteopathic College Accreditation (COCA), who are also members of ACOFPCA.
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Correo *
First Name *
MIDDLE INITIAL
LAST NAME *
STUDENT YEAR FOR CURRENT ACADEMIC YEAR *
COM ATTENDING *
If answered other above, which COM are you attending?
What is your COM student email?  This will be your username for ACOFPCA.org login. *
STREET ADDRESS *
CITY *
STATE *
ZIP *
Cell Phone Number *
Anticipated Month and Year of COM graduation *
HAVE YOU EVER BEEN DENIED MEMBERSHIP? *
Have you ever been denied membership in a County/District of State of Osteopathic Society or have you been convicted of a felony or violation of any state or federal narcotics act?
SIGNATURE *
In signing this form, I certify that the information provided is correct and complete, and do hereby agree to abide by the Constitution and Bylaws of the American College of Osteopathic Family Physician of California. I agree to accept the Board of Governors of ACOFPCA as the sole and only judge of my qualifications to be and remain a member. I understand that any money submitted will be refunded if my application is not approved.
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