2025 Distinguished Fellow Award Application

2026 Distinguished Fellow Application

Submission deadline: November 15, 2025
The ACOFP Distinguished Fellow Award (FACOFP dist.) acknowledges those Fellows who have distinguished themselves through contributions and service to ACOFP by convention attendance, as well as by their support of the ACOFP’s local and national governance and committees.

Candidates must complete at least four of the five Category One requirements and the Category Two requirement since their Fellow induction year. The Distinguished Fellow award in the ACOFP may be conferred on an active ACOFP member in good standing, with no current restrictions on any medical licenses at the time of application, who meets the following category requirements:
CATEGORY ONE

A minimum of four Category One requirements must be completed:
1. Financial Contributions: Contributions of at least $1,500 including donations to the ACOFP Foundation, speaker honorarium donations, and other contributions to ACOFP committee activities or educational program development.
  
  In celebration of ACOFP’s 75th Anniversary, the ACOFP Foundation launched the Family Medicine Forward Campaign, a $750,000 initiative to support the future of osteopathic family medicine. We would like to encourage contributions to this campaign which also fulfill this award requirement. Support of this initiative helps expand key programs like the Future Leaders Conference, which provides leadership training, mentorship, networking, and professional development for early-career physicians.
  
  Please note: Political contributions do not qualify. Documentation must be submitted.
2. Fellow Sponsorship: Sponsorship of three (3) or more completed Fellows. The third Fellow Award sponsorship can occur during the same ceremony they receive their Distinguished Fellow Award.
3. Academic Service: Participation in osteopathic education, not as part of their regular job. Academic service includes presenting or moderating at an ACOFP national, regional, or state convention, precepting osteopathic medical students or having residents on rotation as an elective in a private office setting. Documentation must be submitted of at least three (3) instances of service prior to applying.
4. National ACOFP Service: Participation on a national ACOFP committee, task force, delegate, or ACOFP Board of Governors for a minimum of ten (10) years prior to applying.
5. Affilate Society or Local Service: Participation on an osteopathic family medicine related committee, task force, delegate, ACOFP affiliate society board or local medical/hospital board.
CATEGORY TWO
Candidate must have attended at least twenty (20) ACOFP Annual Convention and Scientific Seminars or AOA Annual Osteopathic Medical Conference and Exposition since their Fellow induction year. Virtual attendance is limited to a maximum of fifty percent of meetings. Attendance in person is required for the convention that you receive your award. Documentation must be submitted.
ADDITIONAL INFORMATION
Fellows who actively have served in the military may request a waiver of this requirement after ten (10) years of active Fellowship.

ACOFP Affiliate Society Presidents may annually nominate two deceased Fellows from their ACOFP society to receive a posthumous Distinguished Fellow Award.

Completed application submission is November 15, 2025 for consideration at the Conclave of Fellows Awards Ceremony during the ACOFP Annual Convention & Scientific Seminars in Orlando, Florida.

APPLICATION
Name of Candidate*
AOA # of Candidate*
Candidate Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Candidate Mobile Phone Number*
Candidate Email Address*
example@example.com
File Upload - Current Curriculum Vitae*

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File Upload - High Resolution Professional Head Shot Photo*

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EDUCATION
Pre-Professional College(s) attended:
Name of School*
City, State*
Year Graduated*
Degree*
Medical School attended:
Name of Medical School*
City, State*
Year Graduated*
Degree*
Internship/Residency Training Program:
Name of Internship/Residency Training Program*
City, State*
Year Completed*
Date of Residency Training Completion

MonthDayYear
Date
Certification Information:
Are you currently certified in family medicine by the AOA or ABMS*
Other
Date of certification residency training completion*

MonthDayYear
Date
Other
Date of when your certification or recertification expires*

MonthDayYear
Date
Other
List current active state licenses*

CATEGORY ONE:

Please select four categories in which you have completed the requirements:
Financial Contributions

Contributions of at least $1,500 total to the ACOFP Foundation, ACOFP speaker honorarium donations and other donations to ACOFP committee activities or educational program development. Political contributions do not qualify.
Financial Contributions Summary
Financial Contributions File upload for documentation

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Fellow Sponsorship

Sponsorship of three (3) ormore completed Fellows.
Fellow Sponsorship 1

First Name of FellowLast Name of Fellow
Fellow Sponsorship 2

First Name of FellowLast Name of Fellow
Fellow Sponsorship 3

First Name of FellowLast Name of Fellow
Academic Service

Participation in osteopathic education, not as part of their regular job. Academic service includes presenting or moderating at an ACOFP national, regional, or state convention, precepting osteopathic medical students or having residents on rotation as an elective in a private office setting.
Academic Service Summary
Academic Service File upload for documentation

Documentation must be submittedof at least three (3) instances of service prior to applying.
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National ACOFP Committee Service

Participation on a national ACOFP committee, task force, delegate, or ACOFP Board of Governors for a minimum of ten years prior to applying.
National ACOFP Committee Service Summary
Affiliate Society or Local Service

Participation on an osteopathic family medicine related committee, task force, delegate, ACOFP affiliate society board or local medical/hospital board.
Regional, State or Local Service Summary

CATEGORY 2 - CONVENTION ATTENDANCE
Candidate must have attended at least twenty (20) ACOFP Annual Convention and Scientific Seminars or AOA Annual Osteopathic Medical Conference and Exposition since their Fellow induction year. Virtual attendance is limited to a maximum of fifty percent of meetings. Attendance in person is required for the convention that you receive your award. Documentation must be submitted.
1)*
Year Attended the Meeting
Name of the Meeting*
2)*
Year Attended the Meeting
Name of the Meeting*
3)*
Year Attended the Meeting
Name of the Meeting*
4)*
Year Attended the Meeting
Name of the Meeting*
5)*
Year Attended the Meeting
Name of the Meeting*
6)*
Year Attended the Meeting
Name of the Meeting*
7)*
Year Attended the Meeting
Name of the Meeting*
8)*
Year Attended the Meeting
Name of the Meeting*
9)*
Year Attended the Meeting
Name of the Meeting*
10)*
Year Attended the Meeting
Name of the Meeting*
11)*
Year Attended the Meeting
Name of the Meeting*
12)*
Year Attended the Meeting
Name of the Meeting*
13)*
Year Attended the Meeting
Name of the Meeting*
14)*
Year Attended the Meeting
Name of the Meeting*
15)*
Year Attended the Meeting
Name of the Meeting*
16)*
Year Attended the Meeting
Name of the Meeting*
17)*
Year Attended the Meeting
Name of the Meeting*
18)*
Year Attended the Meeting
Name of the Meeting*
19)*
Year Attended the Meeting
Name of the Meeting*
20)*
Year Attended the Meeting
Name of the Meeting*
Upload AOA CME Activity Report or ACOFP Meeting Confirmation Report*

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By signing below, I certify that to the best of my knowledge that the information provided on the application is true and accurate.
Candidate Signature*

Clear
Date*

MonthDayYear
Should be Empty:

2026 Distinguished Fellow Application

CATEGORY ONE

CATEGORY TWO

ADDITIONAL INFORMATION

APPLICATION

EDUCATION

Pre-Professional College(s) attended:

Medical School attended:

Internship/Residency Training Program:

Certification Information:

CATEGORY ONE:

Financial Contributions

Fellow Sponsorship

Academic Service

National ACOFP Committee Service

Affiliate Society or Local Service

CATEGORY 2 - CONVENTION ATTENDANCE