Corresponding membership is extended to professionals who meet the criteria for Regular membership and also reside in developing countries. First Name* Last Name* Degree(s):* Birthdate (Year only)* Telephone* Fax Email:* Preferred Mailing Address* City* State/ Province* Zip/ Postal Code* Country* Title Institution/ Organization* Description of Professional Activity and Responsibilities in Teaching, Patient Care and Research.*What percentage of your time do you spend in each of the following areas? Patient Care, Teaching, Research and Student. (Total should equal 100%)*In your present position, do you have administrative duties, e.g.: Chief of Services?*Demographic InformationRaceWhiteBlack or African AmericanAsian & Indian SubcontinentNative Hawaiian & Other Pacific IslanderAmerican Indian or Alaskan NativeOther:EthnicityHispanicNon-HispanicGenderMaleFemaleGender Non-BinaryEducation HistoryUniversity* Degree* Year* University Degree Year Current Discipline (check all that apply):* Psychiatrist Internist Pediatrician Psychologist Socialist Nurse Social Worker Epidemiologist Other If Other: Interests (check all that apply):* Consultation/ Liaison Behavioral Medicine Psychotherapy Pharmacology Physiology Social Systems Biochemistry Epidemiology Central Nervous System Cardiovascular Complementary Treatment Lifespan/ Development Intervention Quantitative Endocrine Immunologic Gastrointestinal Oncology Musculoskeletal Metabolism Pulmonary Renal Genitourinary AIDS Pain Health Services Research Woman's Health Behavioral Genetics Medical Education Diabetes Epigenetics Aging Sleep LGBTQ+ Please indicate how you learned about APS (check all that apply):* Mentor Colleague Printed Material Psychosomatic Medicine Journal APS Website Other If Other: Do you wish to receive a subscription tp Psychosomatic Medicine? A $50 Subscription Fee will be added at the end of this application.*YesNo
