Membership Application

This form will take approximately 5-10 minutes to complete

Please have the following documents/information readily available:

  1. Info item one
  2. Info item two
  3. Info item three

Application Number: 123456

= Required = Optional

Documentation
How would you like to provide your current, valid medical license?
How would you like to provide your residency training completion certificate(s)?
Agreement
In consideration of my membership in the APA, the District Branch and/or the State Association, which I understand is a privilege and not a right, I agree that APA may make inquiries about me and that I am not entitled to the results, that I will pay the dues required on or before the due date, that I will adhere to the standards of ethical practice and conduct as well as the procedures outlined in the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, that APA may publish my membership data in its membership database to which all members and third parties permitted by APA will have access, that APA may provide government authorities all information pertaining to me if in receipt of a subpoena from authorities or if the institution seeking the information is a public institution which has paid all or any portion of my membership dues or CME fees, and that I will hold APA, the District Branch and the State Association harmless from any and all liability arising out of or relating to my membership, including but not limited to, decisions concerning membership, ethics, and/or the provision or storage of my personal and/or fi-nancial information. Any disputes that arise out of or relate to this agreement and/or my membership shall be governed by Virginia law without regard to its choice of law principles and any hearings or proceedings shall be heard in the state of Virginia

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