I do agree that I meet the following requirements and will follow the Association for Medical Ethics by-laws listed below:

1. I am a physician or dentist in good standing with the medical board OF MY STATE AND of my specialty as recognized by the American Board of Medical Specialties.

Please fill in the medical board of which you are a diplomate* (Organization)

2. I am a registered physical or occupational therapist, nurse, physician’s assistant, a physician in training, or other professional in the health care field and am interested in supporting the principles of the Association.

3. If I collect royalties for any patent I own, then it is for a patent that I have genuinely invented and was not “assigned” as a disguised compensation for using or advocating use of a medical product.

4. I do not accept compensation in any form for merely using a medical product as this is both illegal, unethical, and a kickback.

5. I do not accept gifts from any medical manufacturer.

6. I do not own any portion of a distributorship for any products used in my medical practice or training.

7. I agree to expulsion from the Assocation for Medical Ethics for violation of membership requirements.

I fully understand by completing and signing this application that my credentials are being evaluated for participation in AME. I authorize AME, its representatives, agents and subcontractors to investigate information, both oral and written, concerning my application for participation. I agree to allow AME and/or its Agents to inspect and copy all records and documents relating to such an investigation. This authorization includes, but is not limited to, the National Practitioner Data Bank, state licensing board(s), educational institutions, specialty boards, malpractice insurance carriers, hospitals, professional references and any other person or entity from whom/which information may be needed and/or is reasonably relevant to complete the credential approval process. I also understand that if any matter stated in this application is or becomes false, my agreement may be not eligible for admission to the Association.

DECLARATION: I declare under penalty of perjury that my membership information is true and correct to the best of my knowledge and belief. As to that information, I declare under penalty of perjury that the information accurately describes as well, any related information provided to me, and that I believe it to be true.

Dated this day of 2011, in the County of * , State of *

I agree to the membership requirements.