I am applying for membership in the APA through the following District Branch/State Association:
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:
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 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.
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.
Ethnicity/Race (check more than one if applicable.):
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 firstname.lastname@example.org or fax a copy to us at
01.703.907.1085, within 2 weeks of submitting this application.
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.
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.