________________________________Degree_______
Name |
___________________________________________
Address |
| ___________________________________________ |
___________________________________________ |
Office____________________Home________________
Phone Type
of Continuing Education ______________________________ |
Membership Status
|
Fees
(if paid by March 22, after March 22 & on site, add $10) |
| ( ) Nonmember |
$110.00 |
| ( ) Member |
$100.00 |
| (
) Associate Member |
$ 70.00 |
| ( )
Student |
$ 35.00 |
Total:: |
_______ |
|
*Continental Breakfast and Lunch Included*
Please make check or money order payable
to DSPP
|
Please send completed registration and
payment to:
Dallas Society for Psychoanalytic Psychology
4516 Lovers Lane # 446
Dallas, Texas 75225-6993 |