ASSOCIATION  FOR PSYCHOANALYTIC
SELF PSYCHOLOGY

Membership Application Form

Name
___________________________________________________________________________
               (Last)              (First)                     (Degree)

Address
___________________________________________________________________________
               (Street)                       (Apt. No.)

_______________________________________________________  Zip   ______________

Phone (office)
______________________________________________________________

         (home)
______________________________________________________________

Clinical Training
___________________________________________________________________________

___________________________________________________________________________

 

I am interested in becoming a member and I enclose the membership fee of $ 75 ($ 35 for students, retired and those not living in NY, NJ or CT).

Return this form with your dues to:

APSP
215 East 79th Street, Apt. 13C
New York, New York 10021
(212) 288-8592