I am applying for membership in the APA through the following District Branch (in the jurisdiction of my training program):
If YES, please provide your former name if different from current:
APA Promotion Code (if applicable):
Street Address 1:*
Street Address 2:
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:*
Country of Birth:*
Languages Spoken (other than English):
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Degree (M.D., Ph. D., MPH):
Finished or Expected:*
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.]
Finished or Expected *
Add more Residency Training
Psychiatric Residency Endorsement: Resident-Fellow Members
must be endorsed by their training director.
Endorsement: The Residency Training Director, as listed below,
recommends the above applicant for membership in the American Psychiatric Association and
certifies the applicant's psychiatric training as listed above.
APA Id or Phone Number:
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 [email protected] or fax a copy to us at
202-403-3673, within 2 weeks of submitting this application.
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.
Upon completion of psychiatric residency your membership status in
the American Psychiatric Association (APA) and District Branch will be advanced
to that of general member. In order to facilitate this transition please
complete the following authorization allowing your training director to verify
that you have successfully completed your residency. Please feel free to call
the American Psychiatric Association at 888-357-7924 with any questions
you may have.
representative (Training Program Director or Residency Program Coordinator) to
release information about my psychiatric training, including my completion
date, to American Psychiatric Association for the sole purpose of maintaining
and updating my member file. I understand that this information will also be
shared with my District Branch.