Membership Application Form - Canadian Academy of Psychiatry and the Law (CAPL)

Salutation*

Name*

First Last

Country*

Country

Province*

Province

State*

State

Address*

Street Address Address Line 2 City Postal Code

Address*

Street Address Address Line 2 City ZIP Code

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

Category (includes 13% HST)*

Category (includes 14% HST)*

Category (includes 15% HST)*

Category (includes 5% GST)*

Category*

References*

Please provide the names of two CAPL Full Members who can attest to your accomplishments and suitability

Name of 1st reference Name of 2nd reference

Attach a copy of your CV*

CV must have been updated within the last three months. Only .pdf, .doc or .docx files accepted

Accepted file types: doc, docx, pdf, Max. file size: 512 MB.

Attach proof of enrollment*

Written confirmation of enrollment from the department of psychiatry must be provided in English or in French and include postgraduate training year in psychiatry or forensic psychiatry. An acceptance letter is insufficient

Accepted file types: pdf, doc, docx, Max. file size: 512 MB.

Attach proof of enrollment*

Written confirmation of enrollment from the faculty of medicine must be provided in English or in French and must include expected graduation date. An acceptance letter is insufficient

Accepted file types: doc, docx, pdf, Max. file size: 512 MB.

Certification in (general) psychiatry*

Royal College of Physicians and Surgeons of Canada
American Board of Psychiatry and Neurology
Other authority

Specify certification authority:*

Certification in forensic psychiatry*

Royal College of Physicians and Surgeons of Canada
American Board of Psychiatry and Neurology
Other authority
No certification in forensic psychiatry obtained

Specify certification authority:*

Which statement best describes your training in forensic psychiatry?*

I have had least one year of forensic psychiatry training AND have primarily practised forensic psychiatry for at least three years
I have not completed formal training in forensic psychiatry BUT have primarily practised forensic psychiatry for at least five years

Percentage of practice time dedicated to forensic psychiatry*

Please enter a number from 1 to 100.

Type of forensic psychiatry work at present*

Topics of interest in forensic psychiatry*

Method of Payment*

Visa
Mastercard

Card number*

Do not enter spaces or dashes

Card expiry month*

Card expiry year*

CVV*

Declaration*

I certify that the information submitted above is accurate and complete, and agree to abide by the rules and regulations of the Canadian Academy of Psychiatry and the Law (bylaws are available at www.capl-acpd.org). CAPL reserves the right to request additional documentation if required to assess an application.

I agree

Date*