2001 Conference Registration
Form
The First Annual Conference of the AAPI
Perspectives
On An Object Relations Clinical Presentation:
The Process Of Change
Make checks payable to AAPI. Full
payment must accompany registration form. All fees must be paid in
U.S. funds drawn against a U.S. bank. MasterCard is also accepted. Fees
are listed in U.S. dollars.
Please use one form per registration. The form may be photocopied. (Please
print or type.)
| Last Name: | ___________________________________________ Degree(s):______________ | |
| First Name: | ___________________________________________ Middle Initial:____________ | |
| Address: | __________________________________________________________________ | |
| __________________________________________________________________ | ||
| City: | _____________________________________ | |
| State: | ___________________________________________ Postal Code:____________ | |
| Country: | __________________________________________________________________ | |
| Phone Number: | (______) _______________________________ | |
| Fax Number: | (______) _______________________________ | |
| E-Mail Address: | __________________________________________________________________ | |
| Profession: | __________________________________________________________________ | |
| Professional License No.: | __________________________________________________________________ | |
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| Training Status: |
GRADUATE or CANDIDATE |
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| Name of Institute: |
__________________________________________________________________ |
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| Are you an individual member of AAPI? |
YES or NO |
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| Psychoanalytic
Institute(s) that you are affiliated with (please indicate if the
Institute is an affiliate member of AAPI): |
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ |
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| Graduate Student Program School: |
__________________________________________________________________ | |
| Name on MasterCard: | __________________________________________________________________ | |
| MasterCard Number: | __________________________________________________________________ | |
| Expiration Date: | ______________________________________ | |
| Signature: | __________________________________________________________________ | |