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MEMBERSHIP APPLICATION

American College of Forensic Psychiatry

First name, middle initial, last name:

Street, city, state (province), zip code:

Office telephone:

Fax number:

Email address:

Home telephone number (for our office use only):

Present affiliation:

Medical degree/date/institution:

Other advanced degrees:

Currently valid unrestricted license (state and number):

Areas of specialty in psychiatry:

Please describe your experience in the legal system as expert, consultant, forensic institution, other.

Average number of hours per month doing forensic work:

Articles published:

( ) I will send two copies of a recent curriculum vitae

( ) Please find my check in the amount of $220 dollars for one year's membership in the College.

( ) Or bill me for the above

( ) I will submit or send 2-3 letters of reference (attorney, judge, or forensic psychiatrist)

Date:

American College of Forensic Psychiatry
PO Box 130458, Carlsbad, CA 92013

Telephone: 760-929-9777
Fax: 760-929-9803