Clinical Psychology Graduate Student Application/Renewal for

Student Affiliate Program in APA’s Society of Clinical Psychology

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

NAME:_______________________________________________________________________________

                           first                                                            middle initial                                                                    last

ADDRESS____________________________________________________________________________

CITY, ST, ZIP _________________________________________________________________________

INSTITUTION NOW ATTENDING_________________________________________________________

GRADUATE PROGRAM IN______________________________________

YEARS IN PROGRAM _____                                         YEAR OF EXPECTED GRADUATION______________

DATE:__________________                                        PHONE_____________________________________

SIGNATURE OF APPLICANT____________________________________________________________

As a Society Member, you will also have the Society listserve available to you, if you choose to be added to this email "net". This list is used for discussions of topics pertaining to the field, for calendar listings of meetings and events, and for the general purpose of making Society information accessible to a larger audience. If you’d like to have your name added, please check here and list address____________________________________________________

DUES: $30.00 Make check payable to "Division 12, APA". (Canadian students please pay in US Dollars.)

Mail  application to:             Student Affiliate Program

Division 12 Office

PO Box 1082

Niwot, CO 80544