General Membership Application

I am a physician who has completed acceptable psychiatry training (as approved by the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education, the Royal College of Physicians and Surgeons (Canada) or the American Osteopathic Association) and I have a valid license to practice medicine or I have an academic, research or governmental position that does not require licensure.
I am applying for membership in the APA through the following District Branch/State Association:
Please click here to see the APA District Branch/State Association dues.
Are you a former member of APA?
If YES, please provide your former name:

Biographical Information
APA Promotion Code (if applicable):
After making a selection, using a drop down menu, be sure you tab out before advancing to the next data field.
First Name:*  
Middle Name:
Last Name:*  
Suffix:
Email:*    
Preferred Mailing Address:
Street Address 1:*  
Street Address 2:
City:*  
State/Province:*
 
Zip/Postal Code:*  
Country:
Home Phone Number (777) 777-7777:  
Office Phone Number (777) 777-7777:  
Home Fax Number (777) 777-7777:  
Office Fax Number (777) 777-7777:  
Date of Birth (MM/DD/YYYY):*    
Country of Birth:*
Languages Spoken (other than English):
(Hit Shift or Control while selecting to choose more than one item from list)
Degree (M.D., Ph. D., MPH):

Academic Training
Medical School:*  
City:*  
State/Province:*
 
Country:*  
Started (MM/YYYY):*    
Finished (MM/YYYY):*      
Degree:*  
Psychiatry Residency Training (and other medical specialty training, including fellowship programs; list the most recent training first and include copies of training certificates). The APA does not capture additional training outside of psychiatry unless it is a combination (i.e. Family Practice/Psychiatry; Internal Medicine/Psychiatry or Pediatric/Psychiatry) residency training program due to space limitations of the database.
Training Program/School:*  
City:*  
State/Province:*
 
Country*  
Started:*    
Finished (MM/YYYY):*      
Specialty:*  
Training Program/School:
City:
State/Province:
Country
Started:
Finished (MM/YYYY):  
Specialty:

Training
Does the preceding training information reflect recognized completion of residency training in psychiatry approved by the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education, the Royal College of Physicians and Surgeons of Canada, or the American Osteopathic Association?
If YES, how many full years of psychiatric residency training have you completed?
Does the preceding training information reflect recognized completion of residency training in a field other than psychiatry
IF YES, what specialty?
Does the preceding training information reflect recognized completion of psychoanalytic training

Board Certification

Date
ABFP:
ABPN Addictions:
ABPN Child and Adolescent Psychiatry:
ABPN Child Neurology:
ABPN Clinical Neurophysiology:
ABPN Consultation-Liaison:
ABPN Forensic:
ABPN General:
ABPN Geriatric:
ABPN Neurology:
ABPN Pain Medicine:
ABPN Psychosomatic:
AOA Psychiatry:
Psychiatric Administration and Management:
RCPS General:
Other:

Demographic Data
The following categories are for statistical purposes only. This information will not be considered in connection with your application for membership.
Gender:
Ethnicity/Race (check more than one if applicable.):
Are you Spanish/Hispanic/Latino?













Primary Practice Setting:







Ethics
Has your license to practice ever been revoked or suspended?
 
Are you currently charged with illegal or unethical professional conduct by a regulatory or law enforcement agency or by a professional society?
 
Have you ever been found guilty of illegal or unethical professional conduct by a regulatory or law enforcement agency or by a professional society?
 
If YES, to any of the three preceding questions, please furnish details in a confidential communication to the APA Membership Committee Chair and e-mail (in a PDF or jpg file) a copy to us at membership@psych.org or fax a copy to us at 01.703.907.1085, within 2 weeks of submitting this application.

Professional Service
Current hospital or clinical staff appointments (specify location and years)
Private practice of psychiatry (Specify location and years)
Federal service: Armed Forces/NHSC
Branch
Rank
Dates of service

Documentation
Please check all that apply. (To avoid unnecessary delay, be sure to submit appropriate documentation.)
I will fax a copy of my license and residency training completion certificate within the next two weeks to (703) 907 1085.
License is held in:
License number:
Expiration Date:  
A copy of my current, valid medical license is attached with my membership application.   (maximum size 3mb)

A copy of my residency training completion certificate is attached with my membership application.   (maximum size 3mb)

Not required. I am a physician in an academic, research or governmental position not requiring a license.

Agreement
In consideration of my membership in the APA, the District Branch and/or the State Association, which I understand is a privilege and not a right, I agree that APA may make inquiries about me and that I am not entitled to the results, that I will pay the dues required on or before the due date, that I will adhere to the standards of ethical practice and conduct as well as the procedures outlined in the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, that APA may publish my membership data in its membership database to which all members and third parties permitted by APA will have access, that APA may provide government authorities all information pertaining to me if in receipt of a subpoena from authorities or if the institution seeking the information is a public institution which has paid all or any portion of my membership dues or CME fees, and that I will hold APA, the District Branch and the State Association harmless from any and all liability arising out of or relating to my membership, including but not limited to, decisions concerning membership, ethics, and/or the provision or storage of my personal and/or fi-nancial information. Any disputes that arise out of or relate to this agreement and/or my membership shall be governed by Virginia law without regard to its choice of law principles and any hearings or proceedings shall be heard in the state of Virginia.