American board of medical psychology



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 AMERICAN BOARD OF MEDICAL PSYCHOLOGY  
                                                        Society/Student Membership Application 
Introduction:  There are three membership categories that persons may wish to review and understand.  The first is “The Medical Psychology Society Membership”.   This membership level simply requires that the member have an interest in the science and related practices of Medical Psychology and a license to practice psychology, social work, counseling, marital and family therapy, or medicine in at least one state or the military.  The cost of membership for “the society member” is $75 per year with a $10 added fee if the dues are late (email notifications each year).  It should not be represented as a credential of any kind.
The second membership level (Student Member) is for duly matriculated graduate students who are studying one of the disciplines that qualify for society membership above and the fee for this level is $10 per year. 

The third type of membership is for Board Certified Medical Psychologists.  These specialists in Medical Psychology must keep their dues current annually and are also subject to late fees to support the specialty and remain Board Certified. (See the separate application for Board Certification). These Board Certified Specialists approved by the Board after meeting all the rigorous post-doctoral education, residency/preceptorship, and written and oral examination requirements may represent their level of continued membership as a Credential, Specialist Certification, Diplomate in Medical Psychology and this is the only category that can claim membership as involving a credential.

 


Required Data for Application 

Date:  

NAME:  


DATE of BIRTH: 

MAILING ADDRESS:  

CITY STATE:  

ZIP CODE:  

PHONE NUMBERS:  

   Office:                                                         

   Home:  

   FAX: 


   EMAIL:  

Profession:  

Degree Type: Ph.D.       Ed.D.       Psy.D.     MD.      Year Conferred: 

If society or student member application for a behavioral health discipline, please list__________________  

State You are Licensed in and Discipline (if not applying for student member status) and include your state license number for verification. 

Society member applicant list behavioral health discipline __________________, state in which you are licensed _________, and license number for verification_______________.

  

Student member applicant, list behavioral health discipline____________________  



 

 

I have attached my membership fee (or submitted it by PayPal at the web site for  Board Certified Specialist and am currently Board Certified_____, Society Member_____, Student Member_____. 



I have attached my membership fee ______ or, submitted it by PayPal at the web site ____for: 

Society Member_____ 

Student Member_____. 

 

Attestation that you are not currently under license suspension, license sanction, or criminal procedure related to practice:     


I attest that there are none of the actions above that would disqualify (at least currently) me for membership.        Signature________________________________________________________ 

     


As a Society member, I attest that I am not currently under license suspension, license sanction, or criminal procedure related to practice that would disqualify me (at least currently) for membership.        
 Signature________________________________________________________ 


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