Confirmation of the Trainee Status of a Candidate for Membership in the Academy of Psychosomatic Medicine

To be completed by the candidate's training director.

Please complete this form to verify the training status of a candidate for membership in the Academy of Psychosomatic Medicine.

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Candidate's name *   First                      Last
Your name *   First                    Last	Your degree(s) *	Your email *
Your institution *	Your title *
What is the candidate's status at your institution? * Medical Student Intern Resident PM Fellow Other
Start date (MM/YY) *	Anticipated end date *

Please upload verification of the candidate's status at your institution on your institution's letterhead. *

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