Regular __________ Associate _________ Corresponding _________ Name ______________________________ Highest Degree: _____________________ Date of Birth _____________ Telephone: __________________ Fax:____________________ E-mail ________________________ Gender: Male______ Female _____ Race: American Indian ________     Asian ________ American ________ Native HI or Pacific Islande______ African American ________ Caucasian ________________ Others ________________ Ethnicity: Hispanic or Lationo ________ Others ________________ If you are an associate member, what is your expected graduation date? ______________ Mailing Address: ______________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Decription of professional Activity and Responisibilities ---- (attach extra pages if necessary): Teaching _______________________________________________ _______________________________________________________ Research _______________________________________________ _______________________________________________________ What percent 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? ______________________________________

Current Discipline (please circle all that apply): A. Psychiatrist B. Internist C. Pediatrician D. Psychologist E. Sociologist F. Nurse G. Social Worker H. Epidemiologist

Please indicate how you learned about APS(circle all that apply): A. Mentor B. Colleague C. Printed Material D. Psychosomatic Medicine Journal E. APS Website F. Other, please specify __________________________________

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

Educational History (University, Degree, Year);) _______________________________________________________ _______________________________________________________ _______________________________________________________

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.

Prepayment of dues is necessary in order applications to be processed:

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___________________________________

Please send curriculum vitae,completed application and payment to the address below.

American Psychosomatic Society 6728 Old McLean Village Drive McLean, VA 22101 (703) 556-9222 FAX (703) 556-8729 Back to Membership Page