Name______________________________________________
Home Address_______________________________________
City/State/Zip________________________________________
Home Phone ( ) ______________________
Business Address_____________________________________
City/State/Zip________________________________________
Business Phone ( ) ____________________
Fax________________________________________________
E-mail Address_______________________________________
Please use an asterisk to indicate your preferred mailing address.
Highest Degree Earned_________________ Date____________
Place Obtained_______________________________________
Licensure: ___Psychologist ___Professional Counselor
___Clinical Social Worker ___Other____________________
Interest Areas: 1) ______________________
2) ______________________ 3) ______________________
Check those which apply:
___Full Member APA ___Full Member MoPA
___Licensed in Missouri ___Licensed in Illinois
List other memberships/certifications:______________________
Institutional Affiliations (if applicable):______________________
I am applying for membership in the St. Louis Psychological Association as:
___Full Member ($40 Dues) According to the bylaws of the Association, eligibility for full membership requires meeting one of the following criteria: Full Member of APA, Full Member of MoPA, or Licensed Psychologist in Missouri or lllinois.
___Affiliate Member ($40 Dues) Any person who does not meet the requirements of full membership, but has a professional interest in psychology, may apply for Affiliate Membership.
___Student Member ($15 Dues) Any person who is enrolled in a graduate program that is primarily psychological in nature may apply for Student Membership.
___Retired Member ($25 Dues) Any person who has previously been a full member of SLPA, who is over 60, and who has completely retired may apply for this type of membership.
Signed_________________________________________________
Date____________________
___Annual dues enclosed ($40, $25, or $15 as identified above)
Send check made payable to SLPA with application to:
|
SLPA Membership c/o Barbara Levin 12773 Castlebar Drive St. Louis, MO 63146 |
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