New Mexico Psychoanalytic Society

A Local Chapter of The Division of Psychoanalysis, Division 39 of The American Psychological Association

Membership Application or Renewal Form

Please fill out this form completely in order that statistics reported to APA may be as accurate as possible.

Name:______________________________________________________

Address:____________________________________________________

City:_______________________________________________________

State:________________________________Zip Code:_________________

Telephone:(home)_______________________office)______________________

E-mail:___________________________________________

When possible, would you prefer to receive program and conference notifications by e-mail, rather than through the US Postal Service? ( ) yes ( ) no

Your Primary Profession is:____________________________________

Are you a member of A.P.A. Division 39 ? yes ( ) no ( )

EDUCATION (New Members only)

Degree:____________________________________Date:_________________

Your Primary Profession is:______________________________________________

Institution:______________________________________________________

Major Field of Study:_____________________________________________

Mail this form with a check for $60 ($30 for student with copy of student ID) to:

NMPS
P.O. Box 40327
Albuquerque, New Mexico 87196