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*
Phone*
Email*
Enter Email Confirm Email
Category (includes 13% 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*
Only .pdf, .doc or .docx files accepted
Accepted file types: doc, docx, pdf.
Percentage of practice time dedicated to forensic psychiatry*
Please enter a number from 1 to 100.
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*
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) .

I agree
Date*
Date Format: YYYY dash MM dash DD