2024 - 2025 OMT Certification Grant Application

OMT Certification Grant Application for Physicians

Fall 2024 – Spring 2025
As part of the ACOFP Foundation's Initial Certification Grant program, we are pleased to announce a call for applications for OMT Certification. Physicians who completed initial certification within the last 10 years who did not take the practical exam are eligible for up to $900 in funding to complete this portion of the exam. These funds will cover OMT exam fees and up to $500 in travel costs. Partial grants may be awarded.

The application deadline is Friday, February 28, 2025.

Please note: Applicants must register for the exam separately through AOBFP. The following application is just for the OMT Certification Grant subsidy.

If you are a resident, please complete the Initial Certification Grant application here.
Eligibility

To be eligible, the applicant must:
- Be an ACOFP member. Not a member? Join now.
- Take the AOBFP OMT (practical) exam.
- Submit proof of payment of certification fees and travel expense report form.
- Not receive financial support from their employer 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 applyOther
Applicant Name*

First NameLast Name
AOA ID*
AOA ID
Please specify your career stage:*

New Physician-in-Practice (5 years in practice or fewer)Practicing Physician (more than 5 years in practice)Other
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

Browse Files
By submitting your headshot, you give consent for its use by ACOFP for marketing and communications purposes. Cancelof
Date of Birth
OPTIONAL
Race
OPTIONAL
Gender
OPTIONAL
Testing Information
What year did you complete your Initial Certification Written Exam?*
Planned Testing Dates: Practical (OMT)*

Spring 2025Other

Financial Support Requested*

	Enter dollar amount
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 employer that is intended for or could be used for board certification
Total Grant Requested (not to exceed $900)

*Please note: ACOFP Foundation does not reimburse for late fees. Please be sure to include your exam fees only in your dollar amount.
I attest that my employer does not provide financial assistance for the exam fees associated with the AOBFP OMT practical exam.*

Yes, I confirm that these fees are not covered by my employer.No, my employer does provide financial assistance for these fees.
AOBFP practical (OMT) 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 OMT Certification Grant Program.I am NOT interested in engagement opportunities with organizational supporters of the ACOFP Foundation OMT 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.
Applicant Signature*

Clear
Should be Empty:

OMT Certification Grant Application for Physicians

Contact Information

Testing Information