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ASSOCIATION FOR PSYCHOANALYTIC THOUGHT

MEMBERSHIP APPLICATION 2007 – 2008

Member Status: 

______ Renewal         ______Individual ($75)          ______Sustaining Member ($100)

______ 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____________________

PLEASE CHECK HERE TO HAVE YOUR E-MAIL ADDRESS  INCLUDED IN THE LIST SERVE OF THE BALTIMORE WASHINGTON CENTER FOR PSYCHOANALYSIS --To Receive Information and Referrals):___________

 
Member Dues:  Enclosed is a check made out to APT for __________
                           Membership dues for the 2007-2008 fiscal year include September 1, 2007
                           Through August 31, 2008.

 To be included in the 2007-2008 APT Directory, please return this form by September 15, 2007,

 Please send this completed form and payment to:

            Marc Jacobs, Psy.D., Treasurer
            3109 Guilford Avenue
            Baltimore, MD 21218

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