Before You Complete the Application For Membership...
If you are not applying for Student Membership, you will be asked to provide the name of an ACLM sponsor on the application below. If you do not know a member of the College who might serve as your sponsor, contact the ACLM at 847-969-0283 or email us at info@aclm.org for names of members in your state.
Do not proceed with completing the application below until you have a sponsor's name!
See Below
 
ACLM MEMBERSHIP APPLICATION
1100 E. Woodfield Road Suite 350 Schaumburg, IL 60173
Phone: 847-969-0283 Fax: 847-517-7229
Email: info@aclm.org
Applicant Information
First Name:* Last Name:* Degree(s): Gender:*
Birthdate:* Institution: Department: Office Address:*
Office City:* Office State: Office Zip/Postal Code:* Office Country:*
Office Phone:* Office Extension: Office Fax: Email Address:*
Home Address:* Home City:* Home State: Home Zip/Postal Code:*
Home Country:* Home Phone:* Mailing Preference:* How did you hear about us?
       
Membership Categories*
A professional with either an MD, DO, or DDS degree AND a JD degree, all degrees from accredited schools, and licensed to practice in either profession. ($100 member application fee; $295 annual dues)
An applicant who resides permanently in a country other than the United States or Canada, and who has both a Medical Degree, Doctor of Osteopathy, or Dental Degree and a Law Degree, or their equivalents, is teaching or practicing medicine, osteopathy, dentistry or law in accordance with applicable laws or governmental regulations along with documentation to verify that the applicant is lawfully permitted to practice or teach Medicine, Dentistry, Osteopathy or Law in the country of residence. ($100 member application fee; $295 annual dues)
A physician, attorney, dentist, nurse, health science professional, or other person with recognized medical-legal expertise and the appropriate degree from an accredited school. ($100 member application fee; $195 annual dues)
A medicolegal professional residing outside the U.S. or Canada. ($100 member application fee; $195 annual dues)
A full-time student in an accredited professional medical, dental, or law school. (no application fee; $35 annual dues; Sponsor not required)
 
Sponsorship
All applicants other than "Student," must provide one sponsor. You must print the sponsor request form and have your designated sponsor sign and mail the form to the ACLM office for your application to be considered complete. Applicants for "Fellowship" status must be sponsored by a "Fellow." Please indicate the name of an ACLM member who will serve as a sponsor of your application in the space provided. If you do not know a member of the College who might serve as your sponsor, contact the ACLM at 847-969-0283 or email us at info@aclm.org for names of members in your state.
Sponsor:
 
Education Information
Please be as thorough as possible
Undergraduate Training *
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Postgraduate Training (Exclusive of Medicine & Law)
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Medical or Dental (Approved schools only)
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Postgraduate and Residency
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Fellowship
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Legal (Approved schools only)
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Postgraduate Legal
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Nursing
Name of Institution: City: State: Dates Attended:
Date Completed: Degree(s) Earned:   (mm/yyyy - mm/yyyy)
   
 
Current Information
You must mail proof of licensure to the ACLM office in order for your application to be considered complete.
Medical
State/Province: Date of Licensure or Admission to Practice: Licensure Number:
 
Dental
State/Province: Date of Licensure or Admission to Practice: Licensure Number:
 
Legal
State/Province: Date of Licensure or Admission to Practice: Licensure Number:
 
Nursing
State/Province: Date of Licensure or Admission to Practice: Licensure Number:
 
Other
State/Province: Date of Licensure or Admission to Practice: Licensure Number:
 
Certificate Information
If certified by a specialty examining board in a specialty or sub-specialty, please list name of each certifying board, category and date of certification:
 
Medical/Dental or Legal Society/Association Memberships
Please indicate those societies of which you are a member (current membership in one of these organizations is required for Fellowship):
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Offices Held (if any):
Dates of Membership (inclusive):
 
Please list any other state or county associations or Canadian equivalents of the above of which you are a member:
 
Name of Association: Offices Held (if any):
Dates of Membership (inclusive):
 
Name of Association: Offices Held (if any):
Dates of Membership (inclusive):
 
Name of Association: Offices Held (if any):
Dates of Membership (inclusive):
 
Hospital Appointments
Please list name of institution, your title, and inclusive dates:
 
Academic Appointments
Please list name of institution, your title, and inclusive dates:
 
Public Service*
Do you devote full-time to government or other public service, teaching, postgraduate study or any type of institutional position without any individual private practice?
 
The requirement for a state license is waived while physicians are on active duty with one of the military services.
 
Publications
Please list titles of articles or books, name of journal or publisher, and date of publication:
 

In addition to submitting this application, and to complete your application, you must forward the following information to the ACLM office at *
American College of Legal Medicine
1100 E. Woofield Road, Suite 350
Schaumburg, IL 60173

1) Copy of your current legal, medical, dental or health care license from at least one state (If you are applying for fellowship status, you must include proof of licensure in one profession and proof of degree in the other.)
2) If you are applying for student membership, please mail proof of current full-time matriculation in an accredited law, medical, dental or health care school (letter from registrar, copy of current transcript, etc.).
3) Print the Sponsor Request Form and send it to your designated sponsor, unless applying for student membership.
4) If paying application fee by check, please forward payment to ACLM office.
 
Payment Information (must be made in U.S. dollars)
Billing Address:* Zip:* Card Type:*  
 
Name on Card:* Card Number:* Expiration Date: (mmyy)* Card Verification #:*
Total Amount Due:
 
Note: Upon submission, if all the required information is entered you will see a review of your submission and be sent an email to the email address you entered. Please contact the ACLM at (847) 969-0283 if you have any questions.