2020 CORRESPONDING MEMBERSHIP INFORMATION AND APPLICATION





*First Name:
*Last Name:
*Degree:
*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

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?

 

Demographic Information

Race: White
Black or African American
Asian & Indian Subcontinent
Native Hawaiian & Other Pacific Islander
American Indian or Alaskan Native
Other:
 
Ethnicity Hispanic
Non Hispanic:
 
Gender: Male
Female
Gender non-binary
 

Educational History

*University
*Terminal Degree
*Month/Year

University
Degree
Year

University
Degree
Year

*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
Lifespan/Development
Intervention
Quantitative
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
LGBTQ
 

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

Mentor
Colleague
Printed Material
Psychosomatic Medicine Journal
APS Website
Other
 
 

*Do you wish to receive a subscription to Psychosomatic Medicine?
A $50 Subscription Fee will be requested at the end of this application.

Yes
No