Application Form

Application for Membership

in the Academy of Psychosomatic Medicine

1.

Applicant Information

2.

History, Activities, Education

3.

Certifications, CV, Signature

Please fill out this form in its entirety. You must attach your CV on page 3.

If you are applying for membership as a postgraduate fellow, resident, intern, or medical student, your training director must submit the online Trainee Status Confirmation form.

* required

TYPE OF MEMBERSHIP

You will be invoiced for membership dues after you have been approved for membership in the Academy.

I wish to apply for membership as:

FULL MEMBER ($225) — psychiatrist actively engaged in psychosomatic medicine (PM), C-L psychiatry, or medical psychiatry

ASSOCIATE MEMBER ($175) — individual with advanced degree in a related field and actively engaged in PM,

C-L psychiatry, or medical psychiatry

POSTGRADUATE FELLOW/RESIDENT/INTERN/STUDENT ($55)

APPLICANT INFORMATION

First name *	Middle name or initial	Last name *
Graduate degree(s)	Date of birth * MM/DD/YYYY
Preferred mailing address for APM mail * Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country
Your email *	Office phone *	Mobile phone *

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