This page may be printed out, completed and mailed to the address below:

ASSOCIATION FOR PSYCHOANALYTIC THOUGHT

MEMBERSHIP APPLICATION 2009 – 2010

Member Status: 

______ Renewal         ______Individual ($115)          ______Sustaining Member ($140)

______ New Member            ______ Student ($25)                         

Member Information:

            Name/Credential as you would like to be listed in the Directory:

            ________________________________________________________

            Discipline:  _______________________________________________________

            Address:  _________________________________________________________

                            ________________________________Zip Code_________________

 
            Phone:  (H)_________________________        (O)________________________

                          E-Mail___________________________  FAX____________________

 
Member Dues:  Enclosed is a check made out to APT for __________
                           Membership dues for the 2009-2010 fiscal year include September 1, 2009
                           Through August 31, 2010.

Note: Dues may be deferred and paid in three installments.

To be included in the 2009-2010 APT Directory, please return this form by September 30, 2009.Please send this completed form and payment to: Marc Jacobs, Psy.D., Treasurer

3109 Guilford Avenue  

Baltimore, MD 21218

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