PAFP Form No.

M-01
PHILIPPINE ACADEMY OF FAMILY PHYSICIANS
#2244 Taft Avenue, Malate, Manila
Tel. 516-2900; Tel./Fax No. 254-5646

2X2 PICTURE
INFORMATION SHEET FOR APPLICANTS FOR MEMBERSHIP

Regular Associate

PLEASE PRINT:

____________________________________________________________________________________________________________
FAMILY NAME GIVEN NAME MIDDLE NAME

ADDRESS: Residence:____________________________________________________________________________________
Office :____________________________________________________________________________________
Preferred Mailing Address ( ) Residence ( ) Office/Clinic
Mobile No._______________________________ Telephone No.:________________________________________
Fax No.:_________________________________ E-mail Address:________________________________________
Age:________________ Date of Birth:__________________________ Place of Birth: _____________________________________
Civil Status:_________________________ Name of Spouse:__________________________________________________________
Names of Children: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

School Graduated:_____________________________________________________________ Year: __________________________

Internship____________________________________________________________________ Year: __________________________
Passed Medical Board Exam in year____________________________________ P.R.C. #:___________________________________
Residency (Name of Dept./Hospital)__________________________________________________________Date Started:__________

Present & Past Positions, Employer & inclusive dates (use another sheet if necessary)
Employer Position Year
______________________________________________ _____________________________________ _______________________
______________________________________________ _____________________________________ _______________________
______________________________________________ _____________________________________ _______________________
______________________________________________ _____________________________________ _______________________

PMA No._______________________________ Component Society: _______________________________________________

Membership in Civic/Social Organizations, Positions (use another sheet if necessary)

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Place of Practice: ( ) Private ( ) Government

Hospital/Affiliation _____________________________________________________________________________

Other Special Interests: ________________________________________________________________________________________

Name of Beneficiaries:
Spouse:_______________________________________________________________________________________
Children______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Others (pls. indicate relation to member)_____________________________________________________________

_______ __________________________________________________
Applicant’s Signature over Printed Name

ENDORSEMENTS
(Signature over printed name)

For Regular Member: For Associate Member:

_____________________________________________ __________________________________________________
Department Head President/Secretary of Affiliate Society

(for both regular & associate member)

__________________________________________________
Chapter President (Name of Chapter)
(Revised 2015)
 Committee on Membership

Application Received by: _______________________________________________ Date Received __________________________

Credentials Evaluated by: ______________________________________________________________________________________

Committee Member/En Banc

Recommendation:

( ) Approved ( ) Disapproved ( ) Pending ( ) For Board Deliberation

__________________________________________________
Chairman, Committee on Membership

Board Action:________________________________________________________________________________________________

__________________________________________________
President

____________________________________________
Executive Secretary

REQUIREMENTS FOR APPLICATION

1. Completed Information Sheet
2. 2 copies of 2x2 colored pictures
3. P.R.C card (updated and authenticated xerox copy)
4. PMA card (updated and authenticated xerox copy)
5. Application Fee of P100.00 ( ) Cash ( ) Check
6. Upon approval of membership application, payment of the following fees:

Regular Associate

a) Annual Dues…………………………… P 430.00 P 430.00

b) Journal………………………..………... 200.00 200.00
c) Pakikiramay Plan……………………… 150.00 150.00
d) W.O.N.C.A. …………………...……… 70.00 -
e) Calamity Fund ………………………… 150.00 150.00
f) Special Building Assessment
(payable in full amount or within 3,000.00 3,000.00
three years period)…….…………....
f) Miscellaneous…………………...……... - -