2022-2023 Initial Certification Grant Application

Initial Certification Grant Application

Fall 2022 – Spring 2023
Well-trained osteopathic family physicians are in the best position to improve the health of patients and communities. To remain at the forefront of the ever-evolving health care landscape, we must support the development of future leaders in the osteopathic family medicine community.

In order to relieve some of the financial burden for residents entering the field, the ACOFP Foundation is pleased to announce its call for applications for the Initial Certification Grant. The grant will award up to $1,400 for AOBFP exam fees and travel expenses to residents who don’t have complete funding support from their program. Partial grants may be awarded.
Eligibility

To be eligible, the applicant must:
- Be an ACOFP resident member. Not a member? Join now.
- Take both the AOBFP initial written and practical exam (Early Entry Initial Certification or standard Initial Certification pathways are acceptable.)
- Submit proof of payment of certification fees and travel expense report form.
- Not receive financial support from their residency program sufficient to cover the entire cost of the AOBFP exam and travel. Partial grants may be awarded.
- Submit completed W-9 form.
Contact Information
How did you hear about this grant opportunity?*

ACOFP EmailACOFP WebsiteACOFP Presentation/PowerpointACOFP BoothAOA WebsiteProgram Director, Faculty or CoordinatorOFP JournalSocial MediaFriendAOBFP (Email, Website, Staff)WebinarCheck if all apply
Applicant Name*

First NameLast Name
AOA ID*
AOA ID
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above, this is where your reimbursement will be mailed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of Permanent Residency*
If different from mailing address above
Phone Number*

Area CodePhone Number
Email (please use personal email address)*
example@example.com
Bio
Tell us about yourself
Headshot

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Date of Birth
OPTIONAL
Race
OPTIONAL
Gender
OPTIONAL
Program Information
Residency Program Name*
Sponsoring Institution/OPTI*
City*
City of Residency Program
State*
State of Residency Program
Program Director*
Program Director Phone*

Area CodePhone Number
Program Director Email*
example@example.com
State in Which You Plan to Practice Upon Completion of Residency*
Testing Information
Are you planning to pursue the AOBFP Early Entry Initial Certification program?

YesNo
Planned Testing Dates: Cognitive Exam*

Fall 2022Spring 2023
Planned Testing Dates: Practical (OMT)*

Fall 2022Spring 2023

Financial Support Requested*

	Enter dollar amount
AOBFP Written Exam Fee*
AOBFP Practical Exam Fee*
Estimated Travel* (Max. $500), includes airfare, mileage, parking, cabs/Uber/Lyft and/or lodging. Mileage is calculated at $0.58/mile.
Amount of financial support from your residency program that is intended for or could be used for board certification
Total Grant Requested (not to exceed $1,400)

*Please note: ACOFP Foundation does not reimburse for late fees. Please be sure to include your exam fees only in your dollar amount.
AOBFP cognitive (written) receipt

Browse Files
Optional Cancelof
Completed and signed W-9

Browse Files
Optional Cancelof
Engagement Opportunities

Funding for Initial Certification Grants comes from a variety of donors, including ACOFP members and organizational partners. If you are awarded a grant, the Foundation asks that you provide a written or video testimonial and complete a brief survey about your experience.

Optional engagement opportunities with organizational supporters exist for interested recipients. Your willingness to engage with our donors will help ensure that residents who come after you will have access to this program.

If you are interested in engaging with these program supporters, please opt in below. Your decision to opt in will have no impact on the outcome of your grant application.
Select one:*

I am interested in engagement opportunities with organizational supporters of the ACOFP Foundation Initial Certification Grant Program.I am NOT interested in engagement opportunities with organizational supporters of the ACOFP Foundation Initial Certification Grant Program.
SIGNATURE INSTRUCTIONS

APPLICANTS: Please use the 'Applicant Signature' e-Sign field below to sign your application. When you have finished, press the 'submit' button at the bottom of the form. This will send an email of your form to the email you have given for your program director. They will be given a link to add their signature to this form. Please confirm that they have received this email.

PROGRAM DIRECTORS: If you are reading this, you have received the email mentioned above. If you have not yet done so, click the link at the top and scroll down to the 'Program Director Signature' box and e-sign. Once you have signed, please press the 'submit' button at the bottom of the page. You may wish to notify your applicant that you have done so.
Applicant Signature*

Clear
Program Director Signature (See Signature Instructions)

Clear
Should be Empty:

Initial Certification Grant Application

Contact Information

Program Information

Testing Information