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Central
Pennsylvania Psychological Association
Application for Membership or Renewal, (
Circle One) - 2006. 2007, 2008
Please complete and send this form by with a check made payable to CPPA to:
CPPA, P. O. Box 1372, State College, PA 16801
Membership Category
Dues/Year
Member
$30
I am a psychologist living or working in Central Pennsylvania,
and I
meet membership requirements of (check at least one):
The Pennsylvania Psychological
Association (PPA)
The American Psychological Association (APA)
Associate Member
$20
I am a student
enrolled in a graduate program in psychology, and I do not work
more than 20 hours per week as a psychologist. (Certification
of student status by academic advisor is required.)
I am a non-student
psychologist-in-training preparing for the professional
licensure exam.
I am none of the
above; however, I am interested and/or involved in promoting
psychology in Central Pennsylvania.
Date:
_________________
Amount Enclosed: $ __________
Name:
_____________________________________________
Degree: ____________
(please print)
Office Address:
_____________________________________________
_____________________________________________
E-mail:
____________________________________________________
Telephone:
(
) _____________
Fax: ( )
_____________
Please send CPPA
mailings to the
following address (if different
from above):
_____________________________________________
_____________________________________________
I am interested in
serving on a CPPA committee, please contact me.
I
would like to see the following issues addressed in CPPA
programs:
_____________________________________________
_____________________________________________
Other comments and suggestions for CPPA:
_____________________________________________
_____________________________________________
Please publish my
information in
the CPPA directory (available only to CPPA members):
Yes
No
Please publish my
professional listing on the CPPA website (available to the
public):
Yes
No