AACP_ad.qxp 11/12/07 9:10 am Page 1
The Use of New Technologies in Psychiatric Practice
2008 CME Educational Conference
American
March 14–16, 2008 Academy
Marriott Fishermans Wharf Hotel
of Clinical
San Francisco, California
Psychiatrists
SM
For further information contact Beverly Davidson at aacp@cox.net or 860-635-5533
Your Invitation…
Application for Membership
Your completed application must contain the
following information:
1. Current Position & Contact Information
2. Letter from residency director for resident/
early career psychiatrist
3. Application Fee: $175 Active Member
$90 Affiliate Member
$50 Resident
Name: _____________________________________________
Degree: ____________________________________________
Mailing Address: _____________________________________
City, State, Zip: ______________________________________
Country: ____________________________________________
Telephone: __________________________________________
Fax: ________________________________________________
Cell: _______________________________________________
Email: ______________________________________________
IF RESIDENT:
Residency Director: __________________________________
Address: ____________________________________________
City, State, Zip: ______________________________________
American
Phone: _____________________________________________
Academy
Email: ______________________________________________
of Clinical
I fully release the AACP staff or board to contact any above
noted sponsor or Residency Director to provide information
regarding my fitness for membership in AACP. Such
Psychiatrists
information may include ethical conduct, academic/
professional achievement, current practice and standing in
the professional community. By signing this form I affirm that
my medical license has never been sanctioned or is under
current investigation and that I have never been convicted of
WWW.AACP.COM
any criminal offense. (2005)
Signature: ____________________________ Date: ________
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