APS Membership Form

Dear APS member:  Even though it’s a pain, PLEASE FILL OUT AND RETURN THIS FORM even if you only check one box.  We need this information to keep track of various pieces of data, especially about who is or is not a Division 39 member.

So let’s start with that:

Are you a member of Division 39 of the APA?         Yes_____  No____

APS MEMBER: $70 ______                   APS SCHOLAR (retired professional): $25 _______

MENTAL HEALTH GRADUATE STUDENT OR FIRST YEAR PROFESSIONAL: $25 _____

Nothing has changed so I’m not filling out the rest of this damn form ____________

Thanks for asking, you need the following information on me for your records:

NAME________________________________________________________________________________

WORK ADDRESS (with zip code) __________________________________________________

HOME ADDRESS (with zip code) _____________________________________________________

Work Phone _________________________________ Home Phone _________________________________

Cell Phone _____________________________ EMAIL ADDRESS _________________________________

Where do you prefer mail to be sent?    Home ______________     Work _______________

Degree: _____________________  Discipline:____________________________________________________

Licensed as: __________________________________________________________________________________

Formal psychoanalytic training? ___________________________________________________________

SUGGESTION BOX

Please return form and your dues to: Joyce Cartor, PhD, 7 Forest Court, Knoxville, TN 37919