DIVISION OF PSYCHOANALYSIS (39) AMERICAN PSYCHOLOGICAL ASSOCIATION
Membership Application

(please print)
Last Name:_____________________________________First Name___________________

Highest Degree:______________________________________________________________

Mailing Address______________________________________________________________

City________________________________________________________________________

State:______________________________________________________Zip:______________

Home:  (           )____________________________Office: (            )_____________

Fax:     (           )____________________________Email:______________________

*Important - please check one:
(   )  Yes, you may publish my name and email address on the Division web site
(   )  No, you may NOT publish my name and email address on the Division web site.

Foreign Language Fluency____________________________________________________

States Licensed in: _________________________________________________________

Please provide your APA membership number:___________________________________

Check one and return with your check made payable to:
Division of Psychoanalysis

CHECK ONE:
(   )  Regular / Associate Member ($70.00)
Please activate my membership immediately. I understand that my payment enrolls me into Division 39 membership through December 31 of this year and that thereafter I will be billed by APA on my annual APA dues statement. (You must be an APA member.)

Student Member ($15.00)
(   )  Please enroll my membership. I understand that my dues are paid on a calendar year and will be due on December 31 each year. I also understand that if I join in October through December my membership will begin in January. I also understand that I do not need to be a member of APA to retain membership in Div 39.

Allied Professional ($70.00)
(   )  Non-psychologist holders of postgraduate degrees who are licensed or certified in a mental health discipline and have demonstrated an interest in psychoanalysis through academic training, Institute training, continuing education, writing or related study.

International Affiliate ($45.00)
(   )  NThis status is reserved for International Members of APA and/or graduate students in a mental health discipline.  It is also reserved for other individuals who have demonstrated interest in psychoanalysis.

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Applicant's Signature and Date