APPLICATION FOR BOARD RECERTIFICATION
Important: Carefully
read and answer all questios on this application. If a question
does not apply to
your specialty and/or requirements, please indicate n/a. Incomplete
applications or documents that are
specifically requested but are not included or illegible, will be grounds
for application disqualification.
Faxed applications will not be accepted.
APPLICANT L. Name: ________________________ F. Name:
_____________________M.I. _______________
PrimarySpecialty: _______________________ Secondary Specialty
________________________
Address: _______________________________________________________________________
City: __________________________________ State: _______________
Zip Code: ___________
Country __________________
Phone: ____________________ Fax: ___________________
D.O.B. _____________________
MEDICAL SCHOOL
INTERNSHIP
Name: ___________________________________
Name: _______________________________
City, State/Country _________________________
City, State/Country _____________________
Dates-From ______________ To: ______________
Dates-From: ____________ To: ___________
REQUIRED DOCUMENTATION CHECKLIST
The information listed below MUST be included with
this application to be eligible for recertification (DO NOT FAX). All
items are required.
1. Current Biography/Curriculum Vitae
2. Copy of Residency Certificate(s)
3. Medical School Diploma
4. Copy of Internship Certificate(s)
5. Copy of Original AFMA Supported Board
6. Copies of CME totaling 150 hours Certificate(s)
7. Recertification Fee(s) total $400.00 (includes processing and
AFMA fees)
Check here if you are applying for recertification in more than
one board. You must include a $50.00 processing fee for each additional
board along with your $400.00 payment. Make checks and/or money
order payable to: AFMA.
I hereby certify that under penalty of perjury
of law, the information provided on this application are all true and
there is no ill intent or bad faith involved. I also understand
that any falsification of records, misrepresentations of material, significant
omissions, dishonesty, forgery, and unethical practices will automatically
render
my application null and void.
I agree to indemnify, release and hold harmless
the American Federation for Medical Accreditation (AFMA) and its agents
of any torts by reason of their acts or omissions regarding my application.
I authorize full investigation of my application.
My signature below is an authorization to anyone to release information
you may request on me to help AFMA make an accurate assessment and/or
evaluation of me.
__________________________________________________________
(Name) Date