IMPak - Personal Information

Not Logged in

Personal Information

Membership is limited to members in good standing of the American Academy of Child and Adolescent Psychiatry; the American Psychiatric Association; or the foreign national equivalent to the APA.

Membership dues are payable in U.S. funds at the time of application ($295.00 general; $55.00 residents/fellows; $95.00 outside of North America). Subscriptions to the Academy’s publications are included with membership.

Contact Information

First Name	M.I.	Last Name	Suffix	Credentials
*		*	* (Example: MD)

Title:

Company:

AAPL Status:

Fellow

Resident

Other Associations:

Graduation Years:

Birth Date:

* MM/DD/YYYY

Gender:

Mailing Information

Street Address:	*
Apt.#
City, State & Zip:	* *
Country:
Phone #:	*
Fax #:
Email:	*

Directory Information

Street Address:
Apt.#:
City, State & Zip:
Country:
Phone #:
Email:

Additional Information

AAPL Membership

How Did You Hear About Us?:

Attended and Association Meeting/Course	AAPL Website
Colleague	Association Publication
Other Media	Fellowship Program

Membership

Category:	*
Amount:

* = Required Field

American Academy of Psychiatry and the Law
One Regency Drive P.O. Box 30 Bloomfield, CT 06002
Tel: (860) 242-5450 (800) 331-1389
Fax: (860) 286-0787