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| Part I. |
Personal Information |
| Title |
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| First
Name: |
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| Last
Name: |
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| Middle Initial: |
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| Degrees: |
|
Organization/
Company |
|
| Address
1: |
|
| Address
2: |
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| City: |
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| State: |
|
| Zip/Postal
Code: |
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| Country: |
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| Work
Phone: |
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| Home
Phone: |
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| Fax: |
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| E-mail: |
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| Date of
Birth: |
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| Sex: |
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| Citizenship: |
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| |
| Billing Information |
|
|
Click here if shipping information is the same as billing information. |
| Billing First Name: |
| |
| Billing Last Name: |
| |
| Billing Address1: |
| |
| Billing Address2: |
| |
| Billing City: |
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| Billing State: |
| |
| Billing Zip: |
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| Billing Country: |
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|
Part II
|
Additional
Information
|
| Years in
Practice: |
|
|
| Board
Certification: (If applicable) Please include name of subspecialty board
and date.
|
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|
Do
you have ABPN Subspecialty Certification in Addiction Psychiatry?
Yes
No
Date
Received
|
|
|
American
Psychiatric Association Membership Status:
General Member
Fellow
Life Fellow
Student Member
Non-Member
|
|
| References:
List two members from either AAAP or APA other than associates or
partners. Please include name, addresses and phone number.
|
|
| Periodically we have
various organizations or journals request our mailing list.
Do you wish to
have your address given to requestors?
Yes
No
|
|
|
AAAP Patient
Referral Program – When you participate in the AAAP Patient Referral Program, patients who are seeking treatment in your area will be able to find
your contact information easily.
Would you like
to participate in the AAAP Patient Referral Program?
Yes
No
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By checking this box, I agree to abide by the Charter and Bylaws of
the American Academy of Addiction Psychiatry. I understand that the
organization will review my application and my references. I will hold the Academy, its members, examiners,
officers, employees and agents free from all damage and complaint by
reason of any action taken on this application or by reason of any
subsequent action on membership. I pledge myself to high standards of
ethical practice.
|
|
| Part III |
Annual
Dues: Please check your payment option. |
|
Term
|
Rate
|
Rate
|
Rate
|
Rate
|
Rate |
Rate |
| |
Regular/
Affiliate
Members
|
Retired
Members
|
Residents
|
Medical Students
|
Physicians
1-3 Years out of Residency
|
International
(NON
US/ Canada)
|
|
1 Year
|
$215.00
|
$123.00
|
$60.00
|
$50.00
|
$100.00
|
$205.00
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3 Year
|
$600.00
|
N/A
|
N/A
|
N/A |
N/A
|
$570.00
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| |
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| Part
VI: |
Payment |
| Card
Number: |
|
| Expiration
Date: |
|
| CSV Code: |
|
| |
  |
On the back of your
credit card, you should see three digits that are not part of your credit card
number. These three digits are your Card Security Verification (CSV) number. |
