Please print out this form and mail with
appropriate materials to address
at bottom of page
ABMA BOARD CERTIFICATION Application
Name: _______________________________________________________________
Date of Birth and Birthplace: ______________________________________________
Office Address:_________________________________________________________
City / State / Zip Code: ___________________________________________________
Phone Fax Email: _______________________________________________________
Home Address: ________________________________________________________
City / State / Zip Code: ___________________________________________________
Phone Fax Email: _______________________________________________________
Specialty: _____________________________________________________________
_____________________________________________________________________
Subspecialties:_________________________________________________________
_____________________________________________________________________
Education/Degrees:
Colleges Attended, Dates, and Degrees Granted:
_____________________________________________________________________
_____________________________________________________________________
Medical School (name[s] and address[es]):___________________________________
_____________________________________________________________________
Dates of Attendance: ____________________________________________________
Degree[s] Earned/Date of Graduation: _______________________________________
Internship (hospital name[s] and address[es]):________________________________
_____________________________________________________________________
Dates of Service: _______________________________________________________
Specialty[ies]: __________________________________________________________
Residency (hospital name[s] and address[es]): ________________________________
_____________________________________________________________________
Dates of Service: _______________________________________________________
Specialty[ies]: _________________________________________________________
Fellowships (hospital name[s] and address[es]): ______________________________
_____________________________________________________________________
Dates of Service: _______________________________________________________
Specialty[ies]: _________________________________________________________
Are you certified in any other Specialties? If yes, list certification(s)
and dates.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Medical Licensure (State[s] and number[s].):
_____________________________________________________________________
Current Hospital Affiliation (Names and addresses.):
1. ______________________________________Acupuncture Privileges?
Yes No
2. ______________________________________Acupuncture Privileges?
Yes No
3. ______________________________________Acupuncture Privileges?
Yes No
Membership in Acupuncture Organizations:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Membership in Other Medical Organizations:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Teaching Appointments: _________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Publications (Papers written or read before medical societies.
If published cite reference[s]. Attach separate sheet if necessary):
_____________________________________________________________________
_____________________________________________________________________
Formal Medical Acupuncture Training courses
Please give Title, Sponsoring Organization, Address, Hours of
Training, and Dates of each course.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Additional Medical Acupuncture Training and Seminars (Please
list courses and dates.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
References
Please enter the name, address and phone number for each of
your references below. Attach the confidential letters of reference
from each reference to this application.
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
Date and Signature of Applicant (This application must be signed
and dated.)
_____________________________________________________________________
If necessary, use additional sheets of paper
to provide complete information in your application.
ABMA Affidavit
Please complete, sign and date the ABMA
Affidavit and attach it to this application with all other
required information.
Certification APPLICATION FEES and check list
IMPORTANT (Check that the following documents are enclosed
with this application):
- A copy of active State License.
- Certificate(s) of training in acupuncture.
- 3 Confidential letters of reference in
sealed envelopes.
- Signed and dated Affidavit.
- Total fee in U.S. dollars enclosed/or
credit card info completed.
- Signed and dated Application Form.
CERTIFICATION examination and PROCESSING
FEE $750 ($250 processing fee/$500 examination fee)
Certification Application Only Processing
Fee $250
(For applicants who have previously passed the examination
requirements.)
FEE enclosed $_____________
Board Certification Application processing fee must accompany
completed application and is payable only in U.S. dollars.
Payment may be made via check, money order, or Visa and MasterCard.
Make check or money order payable to and mail to:
DIRECTOR OF board certification
AMERICAN board OF MEDICAL ACUPUNCTURE
1970 E. Grand Ave., Ste. 330
El Segundo, CA 90245
310/364-0193 voice 310/364-0196 fax
If paying by credit card please fill out information below:
Visa MasterCard
Credit Card Number______________________________ Expiration
Date__________
Name As It Appears on the Credit Card ______________________________________
Signature As It Appears on Credit Card
________________________________________________ Date ________________
FOR OFFICE USE
ONLY -DO NOT WRITE IN THIS SPACE
Fee Received / Date _____________ Received by the Secretary
_________________
References Completed ________________ Action _____________________________
Referred to the Certification Board _________________Action____________________
Presented the the ABMA ____________________Action________________________ |
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