Personal Information

First Name

Middle Name

Last Name

Date of Birth

Current Title & Affiliation

Contact Information

Office Address

Office Address Line 2

Office City / State / ZIP
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Home Address

Home Address Line 2

Home City / State / ZIP
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Telephone Number (Office)

Telephone Number (Home)

Email Address

Practice Information

State / Year of Present Licensure
/

License Number

Specialty(s)

Subspecialty(s)

Board Certification   Yes   No

Principal Activities (indicate percentage of time)

How do you foresee your interface with Academy activities and programs?

Personal and Professional Conduct

Have you ever been denied membership by a professional society?
Yes   No

Have you ever been the subject of any civil or criminal litigation or administrative proceedings related to your professional or nonprofessional activities?
Yes   No

Have you ever been convicted of a crime?
Yes   No

Proposer (Letter of recommendation must be submitted by a current NYAM Fellow or Member)

Name of Proposer

Address


AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Telephone

Email

By submitting this application, I certify that the information contained herein is true and correct to the best of my knowledge, and accept and agree that any information found to be false may be grounds for denial of Fellowship.