Corresponding Membership Application

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 Information

Race

Ethnicity

Gender

University*

Degree*

Year*

University

Degree

Year

Current Discipline (check all that apply):*

If Other:

Interests (check all that apply):*

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

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.*