Membership Ambassador Name:
His/Her Member ID (if known):
Member E-mail:
Please enter valid Email.
APA Promotion Code (if applicable):
First Name:*
First Name is Required
Middle Name:
Last Name:*
Last Name is Required
Suffix:
Email:*
Email is Required
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Street Address 1:*
Adress 1 is Required
Street Address 2:
Street Address 3:
City:*
City is Required
CEP/Postal Code:
Country:
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Country Code - City Code - Phone/Fax
Home Phone Number:
Office Phone Number:
Home Fax Number:
Office Fax Number:
Date of Birth:
Please enter valid date.
Country of Birth:*
Date (MM/DD/YYYY):
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Board Specialty:
Country:
Licensing Entity:
Medical School:*
Medical School is Required
City:*
City is Required
Country:*
Country is Required
Started Date:*
Started Month is Required
Started year is Required
Finished Date:*
Finished year is Required
Finished Month is Required
Finished Date must be later than Started Date
Degree:
Training Program/School:
City:
Country:
Started
Finished
Specialty:
Name:
City/Country:
Name:
City/Country:
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)
Medical License is Required
License name as it appears on the license:*
License Name is Required
Full Name:*
Full Name is Required
Country:*
Country is Required
License Number:*
License Number is Required
Expiration Date (If applicable)
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 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.
You must agree to the terms of services before you can submit yor application.
