I am applying for membership in the APA through the following District Branch: Please select District Branch Alabama Psychiatric Society - 60 Alaska District Branch - 71 Arizona Psychiatric Society - 57 Arkansas Psychiatric Society - 1 CALIFORNIA   Central California Psychiatric Society - 4   Northern California Psychiatric Society - 30   Orange County Psychiatric Society - 76   San Diego Psychiatric Society - 64   Southern California Psychiatric Society - 43 Colorado Psychiatric Society - 6 Connecticut Psychiatric Society - 7 Psychiatric Society of Delaware - 8 Washington Psychiatric Society (DC/Metro) - 48 Florida Psychiatric Society - 10 Georgia Psychiatric Physicians Association - 11 Hawaii Psychiatric Medical Association - 12 Idaho Psychiatric Association - 15 Illinois Psychiatric Society - 13 Indiana Psychiatric Society - 14 Iowa Psychiatric Society - 16 Kansas Psychiatric Society - 17 Kentucky Psychiatric Medical Association - 18 Louisiana Psychiatric Medical Association - 19 Maine Assoc of Psych Physicians - 62 Maryland Psychiatric Society - 20 Massachusetts Psychiatric Society - 32 Michigan Psychiatric Society - 21 Minnesota Psychiatric Society - 22 Mississippi Psychiatric Association - 23 Missouri Psychiatric Association - 9 Montana Psychiatric Association - 73 Nebraska Psychiatric Society - 34 Nevada Psychiatric Association - 74 New Hampshire Psychiatric Association - 68 New Jersey Psychiatric Association - 26 Psychiatric Medical Association of New Mexico - 67 NEW YORK   Bronx District Branch - 2   Brooklyn Psychiatric Society - 3   Central New York District Branch - 56   Genesee Valley Psychiatric Association - 5   Nassau Suffolk District Branch – 78   Mid-Hudson Psychiatric Society - 24   New York County District Branch - 27   New York State Capital District Branch - 28   Northern New York District Branch - 59   Queens County Psychiatric Society - 40   Psychiatric Society of Westchester County - 49   Western New York Psychiatric Society - 51   West Hudson Psychiatric Society - 55 North Carolina Psychiatric Association - 29 North Dakota Psychiatric Society - 63 Ohio Psychiatric Association - 35 Oklahoma Psychiatric Physicians Association - 36 Oregon Psychiatric Association - 58 Pennsylvania Psychiatric Society - 38 Puerto Rico Psychiatric Society - 70 Rhode Island Psychiatric Society - 41 South Carolina Psychiatric Association - 42 South Dakota Psychiatric Association - 72 Tennessee Psychiatric Association - 45 Texas Society of Psychiatric Physicians - 46 Society of Uniformed Services Psychiatrists - 77 Utah Psychiatric Association - 61 Vermont Psychiatric Association - 66 Psychiatric Society of Virginia - 47 Washington State Psychiatric Association - 33 West Virginia Psychiatric Association - 54 Wisconsin Psychiatric Association - 52 Wyoming Assoc of Psychiatric Physicians - 75 CANADA   Ontario District Branch - 37   Quebec & Eastern Canada DB (PQ, NF, PEI, NB, NS) - 39   Western Canada DB (MB, SK, AB, BC, NWT) - 53

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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.]

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?

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.

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: Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe, Middle East Armed Forces Pacific California Canal Zone Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Northwest Territories Ohio Oklahoma Oregon Pacific Islands Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon

  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 [email protected] APA’s Ethics Committee may follow up with you in the event it receives notice of an action or investigation from you.