QUALIFICATIONS
Any person currently enrolled in Medical School. Sorry but we cannot accept other types of students as members.

INSTRUCTIONS
Processing of an application may take up to 2 weeks and cannot begin until the College has received a completed application form. Membership is not automatic; qualified applicants are entered by staff after review.

Please complete the application form below and submit. Medical student membership is complimentary. You will not be charged annual dues. If you have any questions or concerns, please email student@acog.org or membership@acog.org.

Complete Name:		*required
Address (line 1):		*required
Address (line 2):
City:		*required
State/Province:		*required
Country:
Zip/Postal Code:		*required
Daytime Phone:
Email Address:		*required
Citizenship:		*required
Date of birth:		*required
Social Security Number:
Gender:		Male      Female *required
Miliary Active Duty:		No         Yes
Rank & Branch of Service:
Undergraduate Training:		College and Location *required Dates of Attendance  *required Month/Year to Month/Year College and Location Dates of Attendance  Month/Year to Month/Year
Medical Education:		Institution and Location *required Dates of Attendance     *required Month/Year to Month/Year Institution and Location Dates of Attendance     Month/Year to Month/Year
		Please explain if medical schooling is longer or shorter than 4 years in duration:
Current Year in Medical School:		1st     2nd     3rd     4th *required
Anticipated Graduation Date:      *required
Does your school have an ob-gyn or women's health group?:      No         Yes
If Yes, Name of Organization:
Contact Person/Phone (if known):
Medical Society Memberships (if any):
I am also considering specializing in one or more of the following:       Family Practice    General Surgery    Internal Medicine    Pediatrics       Other:

Periodically, ACOG sends electronic mail covering current issues. If you do not wish to receive these notifications, please respond by checking this box.

Statement of Authorization

I hereby apply for Medical Student status in the American College of Obstetricians and Gynecologists and certify that the statements contained in the application are true to the best of my knowledge. I agree to abide by the bylaws, rules and regulations of the College if granted Medical Student status.

Type your complete name below to act as your digital signature
*required