Fellowship Fast Track Application

AMWA Fellowship Program FastTrack Application

If you are already a Fellow of a recognized professional medical society (such as the ACP, ACOG, ACS etc), you may qualify for our special “fast track to AMWA fellowship” program. Qualification for fast track will be determined by the fellowship committee. Applicants for fast track must have served AMWA in a leadership capacity and have worked towards AMWA’s mission to advance women’s health and women in medicine.There is a program application fee of $199. Applications are due Dec. 10 every year. Applications received after that time will be reviewed the subsequent year.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Mailing Address*
Institution*
Please indicate your fellowship designation in another society (list the name of the organization - not just the acronym)*
Fellowship Interest Questions
Are you a current AMWA member?*

YesNo
Please list leadership positions you have served in AMWA (indicate years). Please list these individually, rather than refer to your CV.*
Have you ever been convicted of a felony or misdemeanor? *

YesNo
Have you ever had your medical license revoked or suspended? *

YesNo
Have you ever faced disciplinary action from your State Medical Board? *

YesNo
Are you board certified? *

YesNoN/A
If you selected N/A, please state reason below.
If you are currently retired, were you board certified while in practice? *

YesNoN/A
In what medical specialty are (were) you certified?*
Please upload your C.V.*

Upload a File

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The following information will be used if you are selected for fellowship.
Please upload a headshot.*

Browse Files

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Name as you want to appear on the fellowship certificate*
Please upload a copy of the photo release form at bit.ly/photore_lease*

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Fellow Application Fee*

Fellow Application Fee$199.00

Application Fee for AMWA Fellow Designation Review

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

To the best of my knowledge, all information furnished by me in this application and in the supporting documentation is true and complete. I further understand that my election to Fellowship may be publicized in national/local or international press. I affirm that all professional licenses granted to me are in good standing, and that I have not been the subject of disciplinary action. I understand that, in order to evaluate my application, AMWA may review my credentials. I agree to cooperate in such review and allow others to provide information regarding my credentials. I affirm that I will support AMWA's mission and vision and continue to uphold the highest standards of excellence as exemplified by the standards and traditions of the American Medical Women's Association. I also understand that if elected for fellowship status with AMWA, I can retain the use of the credentials "FAMWA" as long as I remain a member in good standing with AMWA.
Signature (Electronic)*
Should be Empty:

AMWA Fellowship Program FastTrack Application

Fellowship Interest Questions