Application: Certified Associate in Medical Staff Development

  • Contact Information

  • Employment Information

  • Please upload a signed and dated letter, on company letterhead, specifying the date that you began your employment and that you are currently employed with that company. *Note: Employment does NOT have to be consecutive. If you have not been employed at your current place of employment long enough to meet the 2+ year FMSD employment requirement, please submit one letter per company for which you were employed in medical staff development prior to your current position.
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  • Professional Membership

  • Please upload a copy of your AAMM membership card.
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  • Qualifying Accomplishments

    In addition to the above criteria you must meet at least 16 credits of professional accomplishment within 24 months of your application date to meet FMSD requirements. Qualifying accomplishments include: Experience Units: One unit for each quarter year full-time equivalent. Continuing Education credits: One credit for each accepted 6 hours of instruction (no limit on the number of credits). Professional Contributions: One credit for each hour taught or each full page published (up to 2 total credits). Awards & Professional Designations: Up to 2 credits. Association Membership: Up to 2 credits.
  • Please upload verification of any continuing education that you have completed within 24 months of the date this form is submitted that you wish to be declared for Professional Accomplishment credit.
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  • Please upload verification of any courses taught, presentations, or lectures given that you have completed within 24 months of the date this form is submitted that you wish to be declared for Professional Accomplishment credit. Please make sure that your verification includes the number of hours taught.
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  • Please upload verification of any articles that you have published within 24 months of the date this form is submitted, that you wish to be declared for Professional Accomplishment credit.
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  • Please upload verification of any awards and/or professional designations, received within 24 months of the date this form is submitted, that you wish to be declared for Professional Accomplishment credit.
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  • Please upload verification of related professional associations that you have belonged to within 24 months of the date this form is submitted, that you wish to be declared for Professional Accomplishment credit. Please make sure that your verification includes the dates you were/are in good standing.
  • Please upload verification of related employment, within 24 months of the date this form is submitted, that you wish to be declared for Professional Accomplishment credit. Please make sure that your verification includes the dates you were/are employed.
  • Verify & Submit

Reminder: After submitting this form, please make sure to return to the email that brought you here and click on the link to initiate processing.