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Print this page, complete, and mail per the instructions below:
Name:__________________________________________________
Address:_________________________________________________
________________________________________________________
________________________________________________________
Home Telephone: (_____)_________-_______________
Office Telephone: (_____)_________-_______________
Email:_________________________@_________________________
APA Membership Status:
__Member/Fellow Associate Member
__Student Affiliate Non-APA Member
APA Membership No.:____________________
SPSMM Membership Status Desired:
__Member (Psychology Doctorate, APA Member/Fellow) • $32
__Associate Member (Associate Member of APA) • $32
__Student Affiliate (Student Affiliate of APA/Includes Journal) • $22
__Affiliate (Interested in SPSMM & Non-APA Member) • $30
Sex: __Male __Female
Race/Ethnicity:
__European-American African-American Hispanic/Latino
__Asian/Pacific Islander American Indian/Alaskan Other
Education
__PhD __EdD __PsyD __MA/MS __MD __Other
Make check payable to Division 51, SPSMM. Send application & check to Division 51 Administrative Office, American Psychological Association, 750 First St., NE, Washington, DC 20002-4242.
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