Association of Medicine and Psychiatry
Membership Application Form

Desired Category:  
__ Member (MDs and DOs)    __ Associate Member (Allied Health Professional)    
__ Resident                __ Student
 
Name in full_______________________________   Degree(s)_________________________
Office Address_____________________________   Telephone_________________________
              _____________________________   Fax_______________________________
              _____________________________   E-Mail____________________________

Home Address_______________________________   Telephone_________________________
            _______________________________

Date of Birth___________   Place of Birth____________   
Citizenship  ___________________   Gender____________

Undergraduate______________________________   Degree(s)_________________________
Education    ______________________________   Graduation Date___________________

Postgraduate ______________________________   Degree(s)_________________________
Training     ______________________________   Graduation Date___________________

Board Certification_____________________________________________________________
Board Eligibility_______________________________________________________________

Licensure  State_____Number_____   State_____Number_____   State_____Number_____

Present   ______________________________________________________________________ 
Practice  ______________________________________________________________________

Previous Positions/ ____________________________________________________________ 
Academic Posts      ____________________________________________________________

Other Professional  ____________________________________________________________
Organizations       ____________________________________________________________

I understand that the Association of Medicine & Psychiatry will review my 
application and make inquires about the information contained on this form.  
I will hold the Association and its officers, members, employees, and agents 
free from any complaint of damage by reason of action taken on my application 
for membership.  If accepted, I will abide by the Association's Constitution 
and Bylaws and pledge myself to the highest standard of ethical practices.

Signed___________________________________________________   Date________________

Return completed application with check for dues to:
Association of Medicine & Psychiatry
1211 Baihly View Lane, SW 
Rochester, Minnesota  55902 
Attn:  Nish Patel
507-280-0190

(Annual dues are $150.00 for Members, $125.00 for Assoc. Members and waived for 
Residents & Students with letter of support from a faculty member.)