Membership Application | Florida Psychoanalytic Center

Type of Membership:*

Name*

First Last

Title/Degree/or Student Status:*

Office Address:*

Street Address Address Line 2 City State ZIP Code

Email*

Office Phone:*

Home Phone:

Cell

Fax

Current Training Institution:

Institute Where You Trained:*

Year Graduated*

Graduate/Medical School:	Year Graduated, or, for Students, Year Expected to Graduate:

Residency/Clinical Internship:	Year Graduated, or, for Students, Year Expected to Graduate:

Other Graduate Training:	Year Graduated, or, for Students, Year Expected to Graduate:

License Number:	State

Liability Insurance Policy (name of carrier):*

Policy Details*

Policy Number:	Amount of Coverage:

Please Upload Your Professional License:*

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Accepted file types: jpg, gif, png, pdf, Max. file size: 12 MB.

Please Upload Your Professional Liability Insurance Policy:*

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Please Upload Your CV:*

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Accepted file types: pdf, doc, docx, rtf, Max. file size: 25 MB.

Other Affiliation:

Place(s) of Practice (Private Practice, Hospital, University, Etc.):*

Years in Practice as a Licensed Clinician:*

Have there ever been any findings of unethical or unprofessional conduct?*

Are there any current or pending charges or allegations of unethical or unprofessional conduct?*

Please explain any "yes" answers above.*

Date*