International Membership Application

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 the APA International Membership Ambassador Program. I am being referred by:
Membership Ambassador Name:
His/Her Member ID (if known):
His/Her 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.