Physician, Fellow, and Resident Membership Application

Join the professional home for all Ohio DPMs. This application is for Ohio, APMA and your local Academy memberships.
- Take your next step, whether you’re starting your career or have an established practice. OHFAMA is here to support you every step of the way.
- Stay at the forefront of podiatric medicine with Ohio’s largest and best educational podiatric programs.
- Connect with other podiatrists locally, statewide, and nationally to find your community.
- Invest in your career—members receive special benefits from our partners, from healthcare to home mortgage rates.

Basic Contact Information

First Name
Middle Name
Last Name
Member Type
Birthday ?
Ethnicity
Spouse's Name

PRIMARY Office/Residency Address

Practice Name
Address
City
State
Zip
Phone
Fax
Email
Website URL

Home Address

Home addresses are never distributed to third parties.
Address
City
State
Zip
Phone
Mobile

Preferred Mailing Address

Please choose your Preferred Mailing Address by selecting ONE of the address types below:
Primary Office Address is Preferred Mailing Address
Home Address is Preferred Mailing Address

Education

Undergraduate Degree:

Year
State
Institution
Degree

Graduate Degree:

Year
State
Institution
Degree

Podiatric Medical Degree:

Year of Graduation
College

Postgraduate Education:

Residency
Begin Date
Completion Date
Institution
State

Military

Military Service
If Reserves, Please Specify branch
Date Entered
Date Separated
Current Rank

Professional Licensure

Podiatric Medical Licenses:
Year State Number
Year State Number
Year State Number
Have you ever had a license to practice podiatric medicine suspended or revoked by any licensure authority?
 
If yes, please Explain in the space provided below.
 
Are you currently, or have you ever been, on probation, suspension, or investigated by any licensure authority?
 
If yes, please explain in the space provided below.
 

Podiatric Medical Practice

Original Start Practice Date ?
Practice type

APMA-Recognized Organizations

(check only those in which you have certification/membership, use CONTROL or COMMAND to multi-select)
Board Certification:
Affilliated/Related Membership
   - denotes required fields