First Name: Middle Name: Last Name: Title: -- Choose -- MD DO PA NP How would you like your name to be printed on your membership certificate? Date of Birth (mm/dd/yy): E-mail: Gender(for statistical purposes only): Male Female Mailing Address: City: State:  Zip: Telephone: Home: Office: Fax: Practice Name: Check if Practice Address is the same as Mailing Address Practice Address: City: State:      Zip Are you the owner of your practice? Yes        No Number of clinic locations Total # of doctors employed at your practice (including you) Your practice setting is (select one): Urgent Care Center Solo Private Practice Group Private Practice Hospital-Based Fast-Track Emergency Department Military Other Please specify: Are you Board Certified? Yes     No If yes, in what specialty(ies)? When does the certification expire? What is the name of the Medical/Osteopathic/Nurse Practitioner/Physician Assistant School you attended: Did you complete a residency, internship or fellowship? Yes     No If yes, in what specialty(ies)? List all states in which you are licensed, including license number and expiration date: Membership Type: -- Choose -- Physician - $325 Senior (aged 65 years or older) - $175 Nurse Practitioner/Physician Assistant - $200 Resident (Currently enrolled in a Residency Program) - $165 Lifetime Member (Physician) - $2000 Lifetime Member (N.P./P.A.) - $750 If you are a resident, what year do you anticipate completing your residency? How did you learn of the AAUCM? Direct Mailing :– What did you receive? Search Engine :- Which search engine? Journal ad :- Which Journal? Referral :- Name of person who referred you? To access your membership information and various parts of this website, you will need to create a unique username and password. Do not use spaces or special characters. There is no minimum or maximum character lengths, but for your own security, we suggest a minimum of 6 characters using both letters and numbers. These are NOT case sensitive. Create Username Create Password Confirm Password Please select a security question which will assist you in retrieving your username and password should you ever forget them. Create Security Question Select One : -- Choose -- Mother’s maiden name? City where you were born? Name of your first pet? Name of your high school? Create Security Answer By clicking Submit, you will be taken to a secure site where you will be able to enter your credit card information. Physician Member: $325 Physician Assistant and Nurse Practitioner: $200 Senior Physician (Aged 65 years or older): $175 Resident Member (Currently enrolled in a residency program): $165 Life Member (Physician): $2000 Life Member (Physician Assistant and Nurse Practitioner): $750 *All fees are nonrefundable American Academy of Urgent Care Medicine 2813 S. Hiawassee Rd., Suite 206 Orlando, Florida 32835 407-521-5789