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Thank you for becoming a member of the California Podiatric Medical Association. Please complete all fields below to submit your application. For more information on Association dues, please contact Jeannette F. Steed at CPMA at (800) 794-8988 or e-mail jsteed@podiatrists.org. If emailing for dues information, please include your full name and original start of practice date. If you are applying for resident membership, please do not use this form for application. Resident members should contact APMA directly at (800) 275-2762 for membership application and dues information. Again, thank you for becoming a member of the California Podiatric Medical Association, we look forward to working with you!

CPMA Membership Application, fields marked with * are required.

Last Name*

Middle Initial

First Name*

Previous Last Name

If changed due to marriage, divorce, etc.

Sex*

Male Female

Practice Name

Home Address

Home Phone

Please include area code.

Home Fax

Please include area code.

Principal Office/Residency Address*

E-Mail Address

We do not sell or distribute your email address. We use it exclusively to contact you about your CPMA Membership.

Office Phone*

Please include area code.

Office Fax*

Please include area code.

Second Office/Residency Address

Second Office Phone

Please include area code.

Second Office Fax

Please include area code.

Date of Birth*

Please enter a date, MM/DD/YYYY, e.g., 6/17/1956.

Podiatric Medical Degree*

Yes No

Podiatric Medical College*

Year of Graduation*

Podiatric Medical Licenses

Year*	State*	Number*
Year	State	Number
Year	State	Number

Original Practice Start Date*

Please enter a date, MM/DD/YYYY, e.g., 6/17/1996.

Have you ever had a license to practice podiatric medicine suspended or revoked in any state?*

If yes, please explain in comments section below.

Yes No

Are you currently, or have you ever been on probation, suspension or investigation by any licensure authority, state or federal agency?*

If yes, please explain in comments section below.

Yes No

Comments

Please include any answers to the above questions that require explanation.

I understand that after submitting this application, I will be billed for Association dues. Applications for membership will not be processed until dues payment is received by CPMA.*

Please include any answers to the above questions that require explanation.

Yes

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