Fellowship Application - American College of Hyperbaric Medicine

Fellowship Application

GENERAL INFORMATION

Applicant First Name

Applicant Last Name

Business/Organization Name:

Applicant Email Address

Birthdate

ACHM Member ID

Please indicate preferred mailing address: (check one)

Office

Home

Applicant Phone/Mobile Number

Office Address

City

State

Zip Code

Office Phone

Fax

Home Address

City

State

Zip Code

Home Phone

Cell Phone

Average number of hours per week spent in hyperbaric medicine

HYPERBARIC INVOLVEMENT

Please check all that apply and include supporting documentation (must meet at least three criteria):

Letter of recommendation from an ACHM Officer or current Fellow of the ACHM

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Copy of Medical License

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Copy of Board Certification documentation

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Copy of HBO Certification documentation (Subspecialty Certification or ABWH CAQ)

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Curriculum Vitae

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I certify that the information contained in this application is correct and complete, and understand that any recognition granted me must be returned if I have falsified or omitted information. I further certify that I understand that fellowship status is granted upon all of the information in my application, that there is no appeal for an adverse decision by the ACHM, and waive my rights to seek legal remedy should I not be granted fellowship status at this time. In the event that my application is not approved by the Executive Committee, I may re-apply in one year. I am not entitled to a refund. I also understand that being granted fellowship status in hyperbaric medicine will have a ten year life, as long as I maintain membership with the ACHM.

Applicant’s Signature

Date

Since 1983

Physician-Led

Evidence-Based

Hyperbaric Medicine Fellow Application

INSTRUCTIONS

GENERAL INFORMATION

HYPERBARIC INVOLVEMENT