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| In your present position, do you have administrative duties, e.g.: Chief of Services? ______________________________________ |
| Current Discipline (please circle all that apply): | ||
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A. Psychiatrist B. Internist C. Pediatrician D. Psychologist |
E. Sociologist F. Nurse G. Social Worker H. Epidemiologist | |
| Specialties (please circle all that apply): | ||
| 01 Consultation 02 Behavioral Medicine 03 Psychotherapy 04 Pharmacology 05 Physiology 06 Social Systems 07 Biochemistry 08 Epidemiology 09 Central Nervous System 10 Cardiovascular 11 Endocrine 12 Immunologic |
13 Gastrointestinal 14 Oncology 15 Musculoskeletal 16 Metabolism 17 Pulmonary 18 Renal 19 Genirourinary 20 AIDS 21 Pain 22 Health Services Research 23 Women's Health 24 Behavioral Genetics 25 Other | |
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| If applying for Regular membership, you must submit one signature of recommendation from a professional who is highly respected in the field and a CV. If applying for Associate membership, a CV and a letter from your department chair or mentor is needed as an endorsement and student verification. Endorsed by: Date ___________________________________ | |||
| APS will accept an email from the sponsor in lieu of a signature. |
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| Prepayment of dues is necessary in order applications to be processed: | |||
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Please indicate the payment method you are using: Check_______ Cash_______ Credit Card ________ Amount: $__________ If using a credit card please complete the following: Credit Card Number ______________________________________ Visa or MasterCard Only Expiration Date _________________ Signature___________________________________
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