Alexandra Symonds, M.D.

Founder: 1983

Membership Application Form 

Association of Women Psychiatrists

PO Box 28218

Name: Last                                                              First                                                      MI                                   Date: ________

Address: Street                                                                     City                              State/Province        Postal/Zip code                                       

Phone/Office: _______________________________ Home: ___________________________

Fax: _______________________ E-Mail: _______________________________________      

Medical School: ______________________________________________Year of graduation: _____

Psychiatric residency training: ____________________________ Year complete (or to be completed): _____

Postgraduate education: __________________________________________ Year completed: _____

Areas of special interest in psychiatry: _______________________________________________

Board Certification in Psychiatry and Neurology    Yes____ No ____     Other Board Certification: ________

APA Member Yes _____ No _____   AMWA Yes _____ No _____  AMA Member Yes ____ No _____

Member of APA Council/Committee or Other  Yes ____ No ____  Please Specify _____________________

Have you put in a written request to APA President-elect for Committee/Council Appointment? Yes ___ No ___

If yes, which APA component would you like to serve on? ___________________________________

Which AWP Committee would you be interested in chairing or becoming a member of?________________

________________________________________________________________________

Annual Dues    

Enclose your check payable to AWP, Inc.