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Membership Application Form

Your Name
(1) First Name :  * (2) Last Name :  *
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(3) Your Email :  *
(4) Password :  * (5) Re-enter the password :  *
Your Information
(6) Address :  *
(7) Phone :  (8) Office : 
(9) Fax : 
(10) Medical School :  * (11) Year of Graduation :  *
(12) Psychiatric residency training :  * (13) Year completed (or to be completed) :  *
(14) Postgraduate Education :  * (15) Year completed :  *
(16) Areas of special interest in Psychiatry :  *
(17) Board Certification in Psychiatry and Neurology :  Yes No (18) Other Board Certification : 
(19) APA Member :  Yes No
(20) AMWA Member :  Yes No
(21) AMA Member :  Yes No
(22) Member of APA Council/Committee or Other :  Yes No (23) Please Specify : 
(24) Have you put in a written request to APA President-elect for Committe/Council Appointment?  Yes No (25) If yes, which APA component would you like to serve on? 
(26) Which AWP Committe would you be interested in chairing or becoming a member of? 
  
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