Resident-Fellow Member Membership Application

I am a physician in a psychiatric residency training program approved by the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education, the Royal College of Physicians and Surgeons (Canada), or the American Osteopathic Association.

I am applying for membership in the APA through the following District Branch/State Association:

Please click here to see the APA District Branch/State Association dues.

Are you a former member of the APA?
If YES, please provide your former name if different from current:
Biographical Information
APA Promotion Code (if applicable):
First Name:*  
Middle Name:
Last Name:*  
Suffix:
Email:*    
Preferred Mailing Address:
Street Address 1:*  
Street Address 2:
City:*  
State/Province:*
 
Zip/Postal Code:*  
Country:
Home Phone Number (777) 777-7777:  
Office 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):

Academic Training
Medical School:*  
City:*  
State/Province:*
 
Country:*  
Started:*    
Finished or Expected:*      
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:*  
State/Province:*
 
Country*  
Started:*    
Finished or Expected *      
Specialty:

Add more Residency Training

Psychiatric Residency Endorsement:Resident-Fellow Member must be endorsed by their training director.

Endorsement: I recommend the above applicant for membership in the American Psychiatric Association and certify the applicant's psychiatric training as listed above.

Name:*  
APA Id or Phone Number:
Email:*    
Does your residency training program pay for your APA membership dues?
If yes, please list the contact name:
Demographic Data
The following categories are for statistical purposes only. This information will not be considered in connection with your application for membership.
Gender:
Ethnicity/Race (check more than one if applicable.):
Are you Spanish/Hispanic/Latino?












Primary Practice Setting:






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 held liable for civil or criminal sanctions by a regulatory or law enforcement body or by a professional society for illegal or unethical professional conduct?
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, the District Branch and/or the State Association, 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 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 Virginia law without regard to its choice of law principles and any hearings or proceedings shall be heard in the state of Virginia.  
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.
I,give permission to or their 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.