Series of 2002 - Philippine College of Physicians

REQUIREMENTS FOR APPLICATION AS PCP MEMBER
AND OTHER INFORMATION
(Effective March 11, 2015)
I.
Who are qualified to become Members of PCP? (PCP Amended By-Laws October 13, 2012):
a.
b.
II.
What are the requirements to become Members of PCP?
a.
b.
c.
d.
III.
Completed Residency Training in Internal Medicine in a PCP-Accredited Training Program; or Board Certified
Member of a PCP Affiliate Society.
Good moral character and good ethical standing in the profession.
Completed application form with (2) passport size pictures.
Endorsement letters from (2) PCP Fellows in good standing; or (2) current members of the Board of Directors of
the component or affiliate society concerned.
Certified true copy of the Diploma of Residency Training in Internal Medicine; or Board Certification from a PCP
Affiliate Society.
Payment of application fee.
For physicians who had completed the Residency Training in Internal Medicine in PCP accredited
training institutions or recognized institutions abroad, and has the intention of taking the PSBIM
examination, what is the importance of becoming a PCP Member? One has to be a PCP Member before
certification as Diplomate Status.
IV.
What are the requirements to maintain a Member status in good standing of PCP?
V.
What are the benefits of a PCP Member?
VI.
When is the deadline for submission of application: March 30.
VII.
When does the induction as Member take place? During the Annual Convention of the same year of
a.
b.
a.
b.
c.
d.
Earn PCP – CME Units of 250 units annually (fiscal year June-May).
Pay the corresponding annual dues from the time of induction as Member.
Reduced registration fees to annual and midyear conventions.
PCP Assistance Program.
PCP PASA Clinic (Physicians’ Assistance to Start Up a Clinic)
PCP Matching Programs
application (Orientation for New Members).
FOR INQUIRIES:
The Secretariat :
Philippine College of Physicians, 22 nd Floor, One San Miguel Avenue Building
San Miguel Avenue corner Shaw Boulevard, Ortigas Centre, Pasig City 1605
Tel. nos: 910-2250, 910-2252 to 54 Fax no. 910-2251
pcp website: www.pcp.org.ph E-mail address: secretariat@pcp.org.ph
PCP Application as Member 03112015
Passport Size
Picture
APPLICATION FORM AS PCP MEMBER
(Effective March 11, 2015)
I.
II.
PCP CHAPTER WHERE YOU ARE OR INTEND TO BECOME A MEMBER________________.
BIODATA
Last Name
First name
Middle Name
Birthdate _____________________ Nationality____________________
Sex_________Marital Status_____ Name of Spouse_________________________________
Home address_________________________________________________________________
Telephone Numbers:
a. Landline____________________________________
b. Cellphones__________________________________
E-mail address______________________________________
PRC NUMBER ________________ PMA NUMBER________________________
III.
EDUCATION
Institution
Year
Honors
a. Pre-Med____________________________________________________________________
b. MD
___________________________________________________________________
c. Internship __________________________________________________________________
IV.
RESIDENCY TRAINING IN INTERNAL MEDICINE
Institution
Year
Honors
________________________________________________________________________________________
V.
FELLOWSHIP TRAINING
Institution
Year
Honors
_____________________________________________________________________________________
VI.
OTHER POST GRADUATE TRAININGS / COURSES
______________________________________________________________________________
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PCP Application as Member 03112015
VII.
ACADEMIC POSITIONS
Institution / Address
Position / Rank
Inclusive Years
___________________________________________________________________________
___________________________________________________________________________
VIII.
HOSPITAL AFFILIATIONS / POSITIONS
Institution / Address
Position / Rank
Inclusive Years
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
IX.
AREA OF PRACTICE:
CURRENT AREAS OF ACTIVE PRACTICE:
Hospital / Clinic: Complete address including Town / City / Province / Region / Zip Code
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
X.
OTHER PROFESSIONAL AFFILIATIONS:
Society / Organization
Membership Position
Inclusive Dates
____________________________________________________________________________________
___________________________________________________________________________
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PCP Application as Member 03112015
I am applying for a Member status on a voluntary basis and I pledge to abide by the decisions of the
PCP, as a purely private self-limiting organization on all matters related to this application, pursuant to
the By-Laws, rules and regulations and policies of PCP. I further waive and/or quitclaim all rights,
demands, or causes of action, past, present or future against PCP, its Board of Regents or any Board or
individual member thereof in connection with, directly or indirectly, this application.
I hereby certify that the above information is true and correct. I understand that the members of the
Committee on Membership and Credentials may independently verify the data.

SIGNATURE OF APPLICANT
(Over Printed Name)
Date
NOTE : PCP would like to keep in constant communication with all its members and affiliates. Kindly
inform/update us should there be any change in your current mailing address or contact number/s.
FOR PCP USE ONLY:
☐ A. Application Form received on ________________________ by:___________________
☐
B. Documents verified and favorably recommended by the Committee on Membership and
Credentials.
☐
C. Approved by the Board of Regents.
☐
D. Inducted as Member on ________________________________________.
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PCP Application as Member 03112015