Membership Application Form

Name: ___________________________________________________ 

Address: _________________________________________________ 

________________________________________________________ 

Phone: _______________________________ 

Fax: _________________________________ 

E-Mail: ___________________________________________ 

APA Membership Status and Fee:
______ Fellow [$22.00]
______ Member [$12.00]
______ Student Affiliate [$10.00]

_____________________________ APA Membership Number (Important) 

Highest Degree Awarded: __________________________________ 

Major Field of Study: _____________________________________ 

Date: ___________________________
Amount Enclosed: _____________

Signature: ____________________________________________________ 
Don't forget to enclose your dues payment--thank you! 

Return to: 
APA Division Services 
750 First St., NE 
Washington, DC 20002-4242