If YES, please provide your former name if different from current:
APA Promotion Code (if applicable):
First Name:*
Middle Name:
Last Name:*
Suffix:
Email:*
Street Address 1:*
Street Address 2:
City:*
Zip/Postal Code:*
Country:
Home Phone Number (777) 777-7777:
Office Phone Number (777) 777-7777:
Mobile 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):
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Degree (M.D., Ph. D., MPH):
Medical School:*
City:*
Country:*
Started:*
Finished:*
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 residency training program (i.e. Family Practice/Psychiatry; Internal
Medicine/Psychiatry or Pediatric/Psychiatry) due to space limitations of the database.]
Training Program/School:*
City:*
Country*
Started:*
Finished *
Specialty:
Add more Residency 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?
The following categories are for statistical purposes only. This information will not be considered in connection with your application for membership.
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
202-403-3673, within 2 weeks of submitting this application.
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
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 202-403-3673.
License is held in:
License number:
Expiration Date:(MM/DD/YYYY)
A copy of my current, valid medical license is attached with my membership application.
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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.
In consideration of my membership in the APA and the District Branch,
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 if applicable, 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 financial information. Any disputes that arise out of or relate to this agreement
and/or my membership shall be governed by District of Columbia law without regard to its choice of law principles and any hearings or proceedings shall be heard in the
District of Columbia. Upon review and acceptance of an application by the APA, you will be given provisional membership, and full APA benefits, while the District Branch (DB)
reviews the application. Voting rights will not commence until you become a fully recognized member in the DB (including payment of dues) at which time you will be a fully
recognized member of the APA and the DB. If a DB rejects an application, the reason will be provided along with a full refund of payment.
By renewing my APA membership, I am attesting that I either am not aware of any action or investigation by any state board of medicine regarding my license to practice
medicine or that I am aware of such action and will immediately send notice of the action or investigation to APA by electronic mail to apaethics@psych.org. APA’s Ethics
Committee may follow up with you in the event it receives notice of an action or investigation from you.