Board Certification Application
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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________________________



American Board of Medical Acupuncture
1970 E Grand Ave, Suite 330
El Segundo, CA 90245
(310) 364-0193 | (310) 364-0196 fax