2017 REGULAR MEMBERSHIP INFORMATION AND APPLICATION





First Name:* Last Name:* Degree:*
 
 
Birthdate (year only):*
Telephone
(without dashes):*

Fax:

Email:*
 
Preferred Mailing Address:*
City:*

State/Province:*

Zip/Postal Code:*
 
Country*TitleInstitution/Organization*
 


Description of Professional Activity and Responsibilities*

Teaching:
Patient Care:
Research:
 

What percentage of your time do you spend in each of the following areas? (total should equal 100%)*


Patient Care: Teaching: Research: Student:
 
 

In your present position, do you have administrative duties, e.g.: Chief of Services?*

 

Demographic Information

Race: American Indian
  Asian
  Native Hawaiiian or Pacific Islander
  African American
  Caucasian
  Hispanic or Latino
  Other:
 
EthnicityHispanic or Latino
 Other:
 
Gender: Male    Female
 

Educational History

University*Degree*Year* 
 
 
UniversityDegreeYear 
 
 
UniversityDegreeYear 
 
 
 
 

Current Discipline (check all that apply):*

Psychiatrist
Internist
Pediatrician
Psychologist
Sociologist
Nurse
Social Worker
Epidemiologist
Other:
 

Interests (check all that apply):*

Consultation/Liaison
Behavioral Medicine
Psychotherapy
Pharmacology
Physiology
Social Systems
Biochemistry
Epidemiology
Central Nervous System
Cardiovascular
Complementary Treatment
Endocrine
Immunologic
Gastrointestinal
Oncology
Musculoskeletal
Metabolism
Pulmonary
Renal
Genitourinary
AIDS
Pain
Health Services Research
Women's Health
Behavioral Genetics
Medical Education
Diabetes
Obesity
Epigenetics
Aging
Sleep
LGBT
 
 
 

Please indicate how you learned about APS (check all that apply):*

Mentor
Colleague
Printed Material
Psychosomatic Medicine Journal
APS Website
Other
 

Did the use of the Educational Resources section of the APS website influence your decision to become a member?*

Yes No



 

How will you be paying for your membership fees?*

Credit card onlineMail a check