| Prior to beginning your on-line international member application
take a moment to save a copy of your current medical license as a PDF or WORD
document. You will be asked to attach it later to the application prior to
submitting it for approval. Once your application has been approved for
membership you will be sent a dues payment form. Dues must be paid prior to
enrollment as a member of the APA. Once an application has been approved and
the dues payment has been processed, your membership is activated. You will be
notified via an e-mail containing your member ID number along with instructions
for accessing on-line member benefits. Thank you for applying for membership in
the American Psychiatric Association.
|
| My application is being submitted in response to your
Member-Get-A-Member campaign. I am being referred by: |
| Member Name: |
|
| His/Her Member ID: |
|
| Member E-mail: |
|
|
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:* |
|
| Address Type: |
|
| Street Address 1:* |
|
| Street Address 2: |
|
| Street Address 3: |
|
| City:* |
|
| CEP/Postal Code: |
|
| State/Province: |
|
| Country:* |
|
| Home Phone Number: |
Country Code - City Code - Phone/Fax
|
| Office Phone Number: |
|
| Home Fax Number: |
|
| Office Fax Number: |
|
| Date of Birth(MM/DD/YYYY):* |
|
| Gender: |
|
Specialty Board Certification (if applicable)
|
| Date (MM/DD/YYYY): |
|
| Board Specialty: |
|
| Country: |
|
| Licensing Entity: |
|
Professional Training
|
| Medical School:* |
|
| City:* |
|
| Country:* |
|
| Start Date(MM/YYYY):* |
|
| Finished Date(MM/YYYY):* |
|
| Degree: |
|
Post Graduate Psychiatry Training (including residency training)
|
| Training Program/School: |
|
| City |
|
| Country: |
|
| Started (MM/YYYY): |
|
| Finished (MM/YYYY): |
|
| Specialty: |
|
Membership in Medical Societies
|
| Name: |
|
| City/Country: |
|
| Name: |
|
| City/Country: |
|
Documentation
|
To expedite your application process, please complete the section below and attach a copy of your medical license (English or Certified Translation). You can also fax documents to: +1.703.907.1085 or email to:intlmbr@psych.org
Please check all that apply. (To avoid unnecessary delay, be sure
to submit appropriate documentation.)
|
|
Please attach PDF file
or WORD document containing an image of your current medical license now:* (maximum
size 3mb)
|
| License name as it appears on the license:* |
|
| Full Name:* |
|
| Country: |
|
| License Number:* |
|
| Expiration Date (If applicable) |
|
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.
|
Agreement
|
| In consideration of my membership in the APA, 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
to its members, license or sell my name, address, phone number and/or e-mail to third parties, and 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. I will hold APA 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 financial 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.
|
|
|
|