ISPT MEMBERSHIP APPLICATION

It is dues time for 2014. Fees for members are $45 and for students, $25. 
Make checks payable to ISPT.



First Name
Last Name
Degree
Licensure
Practice Name
Address
City
State
Zip Code
Daytime Phone
Evening Phone
E-mail Address
 
Check one:
    Member ($45)
    Student member ($25)
Are you a member of APA?
 
Are you a member of the Division of Psychoanalysis (Division 39)?
 
What programs, events, or speakers would you like the Society to sponsor?