Clinical Psychology Graduate Student Application/Renewal for
Student Affiliate Program in APAs 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 youd 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