Fellowship Application
Members applying for fellow status must do so on the official application form approved by the Board of Directors for the current year or by completing the online form. The completed application, all required documentation and the non-refundable fellow application fee of $1,000 must be submitted at the same time.
Date of Application
-
Month
-
Day
Year
Date
Personal Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name as you want it to appear on your certificate.
Advanced Degree Information
Institution
Graduation Year
Degree
Doctor of Medicine
Doctor of Osteopathic Medicine
Doctor of Chiropractic
Other
Please provide proof of graduation (diploma/transcript).
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Employment Information
Current Employer (RM Practice)
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of Employment
Individual Criteria Information
Years of active involvement in restorative medicine as chief professional activity, exclusive of training.
Leadership Experience (Satisfaction of at least three of the following individual criteria during professional career.)
Active involvement, beyond holding membership, in voluntary health organizations, organized medical societies, or voluntary community health planning activities or service as an elected or appointed public official.
Active involvement in hospital affairs, such as medical staff committees, as attested by the department director or chief of staff.
Active involvement in the formal teaching of medicine or chiropractic to physicians, nurses, students, out-of-hospital care personnel, or the public.
Active involvement in practice administration/management or departmental affairs.
Research in restorative medicine.
Active involvement in ACRM chapter activities as attested by the chapter president or chapter executive director.
Member of a national ACRM committee, the ACRM Council, or national Board of Directors.
Participation as a member of a State licensing board.
A published scientific article or reference material in the field of restorative medicine in a recognized journal or book.
Evidence for Satisfaction of Individual Criteria
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Can be in the form of a resume/CV or a letter from the relevant organizations or boards head or other satisfactory evidence.
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Attestation
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