ASSOCIATION OF PSYCHOLOGISTS IN ACADEMIC HEALTH CENTERS
SECTION OF DIVISION 12
APPLICATION AND DUES INVOICE FOR MEMBERSHIP
YEAR 2015 ANNUAL MEMBERSHIP DUES ARE $60.00 (JANUARY 1 - DECEMBER 31, 2015)
STUDENT (GRADUATE, POST DOC, FELLOW) DUES ARE $15.00
PLEASE PRINT
Name:
Date:
Highest Degree: Ph.D.
Academic/Job Title:
Academic Medical Center/
Medical School
Department/Unit
Address
City:
State/Province:
Phone:
Zip:
Country:
Fax:
Email:
University/School Granting Doctorate:
Member of APA? No
Yes
Year Awarded:
Member of Div. 12? No
Yes
DO YOU WANT INFORMATION ABOUT JOINING DIV 12(Society of Clinical Psychology)?
No
Yes
Other APA Divisions? No
Yes
Division(s):
Member of ABPP?
Yes
Area:
No
Fellow
Division(s):
Are you involved with the American Association of Medical Colleges (AAMC)? How):
Do you want to subscribe to the APAHC Listserv? : No
Yes
Send this application with your $60.00 (Students $15.00) check payable to
APAHC to:
APAHC
c/o 2629 Twin Lakes Way NE
Marietta, GA 30062
9/01/1012