ADMSEP Membership Application and Payment (all electronic)


Overview of Types and Cost of Membership
  
-Active and Emeritus (Voting): 
Benefits inlcude a subscription to Academic Psychiatry, listserv access, ADMSEP newsletter, and members-only ADMSEP web access. The fees are Active: U.S $295, International $350; Emeritus is $135.
-Associate (Nonvoting): 
Benefits include access to listserv, ADMSEP Newletter, and members-only ADMSEP web access. The fees are House Officer $20 or Coordinator/Administrator $20.

Note:  This electronic payment option includes an extra 2.9% surcharge to cover the processing by PayPal.  This is not included in the prices above. With Paypal you may use your credit card, debit card, or do a bank money transfer, just as you would as with any other web based purchase.

Directions:   This is a 3 step process:  tell us about you, choose your membership type, then payment thru PayPal.

Step 1:  Please complete the information below, then click "submit" at bottom.  Questions?  
Please mark the correct box with an "x".  I am a     New Member     Renewing Member
Please "x" the box which depicts the time period you are paying for:
  July 2014-June 2015     July 2013-June 2014   July 2012-June 2013    Other:
 
Last Name    
First Name    
Title (MD, PhD, Ed.D. etc)
Institution Name:    
Street Address    
Address (cont)    
Phone  (e.g.. 223-446-5000)    
Fax (e.g.. 223-446-5000)    
Email    
City/Province    
State    
Zip    
       
Url of your professional profile     
Medical School Affiliation (if different than institution):    
   
     
Current position (enter "x" to as many as apply)  
Lecturer in Human Behavior, Psychopathology, or Clerkship
Clinical Attending for Psychiatry Clerkship
Director or Site Coordinator, Clerkship in Psychiatry
Director, Psychopathology or equivalent course  
Director, Human Behavior, Interviewing or equivalent course
Asst or Assoc Director, Medical Student Education
Director, Medical Student Education   
Director or Vice-Chair, Psychiatry Education  
Chair, Dept of Psychiatry    
Other (fill in the blank)    

If there are other educators in your department who may benefit from joining ADMSEP, please write the person's name here:   
 
   
Please check if you are also currently a member of:    AADPRT      AAP      AACDP      AACAP      
   
Note (Optional):  

**Before you click submit, could you please separately email us a photo of yourself so we may include it with your entry in the admsep online directory?  (in the "members only" area)

Prove you are not a robot spammer

Now click submit below
       


Please note:
-After clicking submit, you should see a web page which echos your responses.  The payment page link will be revealed at that time at the page's bottom.
-However, if you see that you made a mistake at the confirmation page, simply click the "back" button on your browser, make the correction(s), and click submit again (it will be clear from the timestamp which submission is your final version).  You do not have to reenter all the info just to correct a mistake as the form "remembers" what you put in previously.
-Eventually you should recieve a confirmation email which includes your submission content above

Questions/Help? 
-About the application process:   Dr. Gary Beck.
-If you have a question about the form itself, please contact webmaster.

r6/30/14