AAGP Membership Application for Psychiatrists

Founded in 1978, the AAGP provides psychiatrists with a special interest in mental health care of the elderly exceptional professional benefits through educational, informational, and interactive programs. This application will be reviewed and voted upon by the AAGP Board of Directors.

All members should follow the AMA's Principles of Medical Ethics.

Full Member Criteria
1. The applicant must have completed a residency in psychiatry approved by the AMA-ACGME or be certified by the American Board of Psychiatry and Neurology in psychiatry.
2. The applicant must have been or must be actively engaged in the practice of geriatric psychiatry.
3. The applicant must have a major professional interest in the mental health care of the elderly, or devote substantial professional time in connection with public mental health or mental health care delivery systems for the elderly.

Member-in-Training Criteria
A physician who is enrolled in a residency in psychiatry or a fellowship in geriatric psychiatry that is affiliated with an accredited residency program.

Retired Member Criteria
A psychiatrist who is (1) 65 years of age or older, (2) has been a Full Member for one year or more and (3) spends less than 15 hours/week in paid professional activities.

Student
Benefits include an online-only subscription to the association's journal, the American Journal of Geriatric Psychiatry. Regular student membership is $45 per year. Student membership without access to the journal is $10 per year.

2010 U.S. and Canada Annual Dues
Full Member: $300
Retired: $150
Member-in-Training: $75
Student: $45
Student (no access to AJGP): $10

2010 International Annual Dues
Dues are based on World Bank resident country income group catogories
HI and UMI Resident Country: $310
HI/UMI with only an online subscription to the American Journal of Geriatric Psychiatry: $250
LMI Resident Country: $115
LI Resident Country: $50

Membership is for January 1 - December 31, 2010.

If you are applying for membership in conjunction with your AAGP annual meeting registration, do NOT submit your payment here. Payment information should be included ONLY on the meeting registration form. Your membership dues are included in your annual meeting registration by checking the appropriate category.

AAGP dues are not deductible as a charitable contribution for tax purposes. However, they may be deductible as a business expense subject to restrictions imposed as a result of association lobbying activities. AAGP estimates the nondeductible portion of your dues to be 29%.

Required Fields marked with an asterisk (*)

GENERAL INFORMATION
* First Name, Middle Initial
* Last Name
* Degree(s)
* I prefer that you send materials to my	Residence Office
* Preferred Mailing Address
* City
* State
* Zip
Country
* Phone
* Fax
AAGP needs your written consent to fax any AAGP product or service correspondence to you. If you agree to this consent, AAGP will not sell your fax number to third parties. Please note that you can revoke this consent at any time by alerting AAGP in writing.
I provide consent to AAGP to fax me about AAGP/GMHF products and services at the fax number above
* Email
* My secondary address is:	Residence Office
Second Address
City
State
Zip
Country
Phone
If an AAGP member referred you to AAGP, please list his/her name:
EDUCATION
I am certified in psychiatry by the American Board of Psychiatry and Neurology	Yes No
I have a subspecialty certification in Geriatric Psychiatry	Yes No
Residency Year:	1 2 3 4 5 6 N/A
Medical Year:	1 2 3 4 N/A
Medical Degree
Institution
City, State	,
*Do you have a current medical license?	Yes No State/Country:
Residency Training in Psychiatry
Institution
City, State	,
Country
Geriatric Psychiatry Fellowship
Institution
City, State	,
Have you ever had your medical license revoked in any jurisdiction?	Yes No
If yes, where?
What year?
Please explain:	characters left
PROFESSIONAL BACKGROUND
Check organizations of which you are a member
	APA IPA CPA AMA AGS GSA ACNP AMDA
Do you accept referrals?	Yes No
*How would you describe yourself and your work?
Clinician Researcher Educator Student Resident/Fellow
*What is your primary place of employment?
Private practice Hospital Long-term care facility Medical school/university Pharmaceutical industry Government Clinic Other
Other:
DEMOGRAPHICS (optional)
Filling out this section is optional; however, information provided by potential members enables AAGP to respond to inquiries primarily from our members about diversity in the field and membership.
Ethnicity	Select... Caucasian African-American Hispanic Native American Asian
Gender	Select... M F
Check here if you agree with the following statement: I affirm that all information provided is correct to the best of my knowledge.
Any other information we need to know that did not fit on the application? characters left
PAYMENT OF ANNUAL DUES
Please use this secure form to provide us with credit card information for payment of your annual dues.
Name on Card
Billing Address	Copy From Above
Billing City, State, ZIP	,
Billing Country
Type of Card	VISA MasterCard
Card Number
Expiration Date	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2010 2011 2012 2013 2014 2015 2016 2017
Amount	2010 U.S. and Canada Dues $300 (Full Member) $150 (Retired) $75 (Member-in-Training) $45 (Student) $10 (Student-no journal) 2010 International Dues $310 (HI/UMI Resident Country) $250 (HI/UMI - online only subscription to AJGP) $115 (LMI Resident Country) $50 (LI Resident Country)
If you are applying for membership in conjunction with your AAGP annual meeting registration, do NOT submit your payment here. Payment information should be included ONLY on the meeting registration form. Your membership dues are included in your annual meeting registration by checking the appropriate category.

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