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AAAP Membership Application

 
Part I. Personal Information
Organization/
Company
Title
First Name:
Last Name:
Middle Initial:
Degrees:
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
Fax:
E-mail:
Date of Birth:
Sex:
Citizenship:
 
Billing Information
Click here if shipping information is the same as billing information.
Billing First Name:  
Billing Last Name:  
Billing Address1:  
Billing Address2:  
Billing City:  
Billing State:  
Billing Zip:  
Billing Country:  
Part II Additional Information
Years in Practice:
Board Certification: (If applicable) Please include name of subspecialty board and date.

Do you have ABPN Subspecialty Certification in Addiction Psychiatry? 

Yes    No    

Date Received   

American Psychiatric Association Membership Status: 

General Member    Fellow   Life Fellow

Student Member  Non-Member
References: List two members from either AAAP or APA other than associates or partners. Please include name, addresses and phone number. 
Periodically we have various organizations or journals request our mailing list. Do you wish to have your address given to requestors?  Yes    No

AAAP Patient Referral Program – When you participate in the AAAP Patient Referral
Program, patients who are seeking treatment in your area will be able to find your contact
information easily.

 

Would you like to participate in the AAAP Patient Referral Program? Yes    No      
By checking this box, I agree to abide by the Charter and Bylaws of the American Academy of Addiction Psychiatry. I understand that the organization will review my application and my references.  I will hold the Academy, its members, examiners, officers, employees and agents free from all damage and complaint by reason of any action taken on this application or by reason of any subsequent action on membership. I pledge myself to high standards of ethical practice.
Part III Annual Dues: Please check your payment option.

Term

Rate

Rate

Rate

Rate

Rate
 

 

Regular Members/

Affiliate Members

 

Retired Members

 

Residents

 

 

Medical Students

International Members

(Non US/Canada)

1 Year

 
$215.00

 
$123.00

 
$60.00

 
$50.00

 
$205.00

3 Year

 
$600.00

 N/A

N/A

N/A

 
$570.00 
Physicians who are in years 1-3 out of their residency, please contact the AAAP Office for a special discounted membership (202) 393-4484.
 
Part VI: Payment
Card Number:
Expiration Date:
CSV Code:

    On the back of your credit card, you should see three digits that are not part of your credit card number. These three digits are your Card Security Verification (CSV) number.