AAPI Grievance Form – American Association of Physicians of Indian Origin

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Name*
First Middle Last
Designation*
Address*
City*
State*
Zip*
Email*
Contact Phone #*
Date of Birth*
MM slash DD slash YYYY
Gender*
Professional Details
AAPI Member*
- Yes
- No
Member of AAPI Local Patron Chapter*
- Yes
- No
Member of AAPI Specialty Patron Chapter*
- Yes
- No
Member of AAPI Alumni Patron Chapter?*
- Yes
- No
State of License and Number*
License current*
- Yes
- No
Medical School Name and year of graduation*
Residency training location, specialty and year of graduation*
Fellowship training location, specialty and year of graduation*
Work History:*
Grievance
Describe the grievance incident in full details*
Have you submitted your grievance with your AAPI local, Alumni or Specialty chapter?*
- Yes
- No
If you answered above question yes, describe the outcome in detail
Have you submitted your grievance with any other professional organizations*
- Yes
- No
If you answered above question yes, describe the outcome in detail*
Have you submitted your grievance with any other civil rights organizations*
- Yes
- No
If you answered above question yes, describe the outcome in detail
Have you submitted your grievance with any law enforcement agencies?*
- Yes
- No
If you answered above question yes, describe the outcome in detail
Any other previous incidents of disciplinary actions, sanctions, loss of privileges, legal incidents and etc.*
- Disciplinary actions
- Sanctions
- Loss of Privileges
- Legal
- Misc
- None
If answer to any of the above is affirmative please describe in detail etc. **
Your current Legal Representation*
What assistance are you requesting from AAPI*
Upload any relevant documents
Drop files here or

Max. file size: 512 MB.
Consent
Consent*
I verify all the facts stated in this document are entirely true and I endorse it by my signature/initials
Signature

Founded in 1982, the American Association of Physicians of Indian Origin represents a conglomeration of more than 80,000 practicing physicians in the United States.

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