APA

Home :

International Membership Application

Prior to beginning your on-line international member application take a moment to save a copy of your current medical license as a PDF or WORD document. You will be asked to attach it later to the application prior to submitting it for approval. Once your application has been approved for membership you will be sent a dues payment form. Dues must be paid prior to enrollment as a member of the APA. Once an application has been approved and the dues payment has been processed, your membership is activated. You will be notified via an e-mail containing your member ID number along with instructions for accessing on-line member benefits. Thank you for applying for membership in the American Psychiatric Association.

My application is being submitted in response to your Member-Get-A-Member campaign. I am being referred by:

Member Name:

His/Her Member ID:

Member E-mail:

Biographical Information

APA Promotion Code here:

After making a selection, using a drop down menu, be sure you tab out before advancing to the next data field.

First Name:*

Middle Name:

Last Name:*

Suffix:

Email:*

Address Type:

Home

Office

Street Address 1:*

Street Address 2:

Street Address 3:

City:*

CEP/Postal Code:

State/Province:

Country:*

Home Phone Number:

Country Code - City Code - Phone/Fax

Office Phone Number:

Home Fax Number:

Office Fax Number:

Date of Birth(MM/DD/YYYY):

Gender:

Female

Male

Specialty Board Certification (if applicable)

Date (MM/DD/YYYY):

Board Specialty:

Country:

Licensing Entity:

Professional Training

Medical School:*

City:*

Country:*

Start Date:(MM/YYYY)

Finished Date:(MM/YYYY)

Degree:

Post Graduate Psychiatry Training (including residency training)

Training Program/School:

City

Country:

Started (MM/YYYY):

Finished (MM/YYYY):

Specialty:

Membership in Medical Societies

Name:

City/Country:

Name:

City/Country:

Documentation

Please check all that apply. (To avoid unnecessary delay, be sure to submit appropriate documentation.)

Please attach PDF file or WORD document containing an image of your current medical license now: (maximum size 3mb)

License name as it appears on the license:

Full Name:

Country:

License Number:

Expiration Date (If applicable)

Ethics

Has your license to practice ever been revoked or suspended?

Yes

Are you currently charged with illegal or unethical professional conduct by a regulatory or law enforcement agency or by a professional society?

Yes

Have you ever been found guilty of illegal or unethical professional conduct by a regulatory or law enforcement agency or by a professional society?

Yes

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

I agree to abide by the By-Laws of APA. I will hold APA members, officers, employees, and agents free from all damage and complaint by reason of action taken on this application or by reason of any subsequent action on membership, including solicitation of information about my professional conduct.

I pledge myself to standards of ethical practice and conduct as specified in the bylaws of APA. I certify that the above information is accurate, and I understand that inaccurate information can invalidate my application. My checking the box below indicates my signature on the application and agreement to all statements therein.