o  Renewal    o New Application       Affiliation  for Calendar Year 199____200____ (Please indicate.)

NAME:_______________________________________________________________________________

                                                        first                                                               middle initial                                                                   last 

ADDRESS____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

DATE:__________________ TELEPHONE_____________________________

o I affirm that I have Affiliate status in APA. My membership number is________ . Or,

o The enclosed vita/letter/outline demonstrates interest in and active engagement in practice, research, teaching, administration, and/or study in the field of Clinical Psychology.

The statements made in this application correctly represent my qualifications for election to membership; and I understand that if they do not, my membership may be voided.

Signed:___________________________________________________ Date______________

Annual Assessment is $60 US. To expedite your application, please include a check; or your

Visa/Mastercard No. __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ expires ___/___.