2003 CONFERENCE REGISTRATION FORM

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 and Visa are also accepted.  Fees are listed in U.S. dollars.  Please use one form per registration.  The form may be photocopied.

(Please print or type.  If sending by fax, please type or use black ink.)

LAST NAME ______________________________ DEGREE(S)____________________

FIRST NAME __________________________ MIDDLE INITIAL __________________

ADDRESS ______________________________________________________________

CITY __________________________________ STATE __________________________

POSTAL CODE_________________________ COUNTRY _______________________

PHONE NUMBER (____)_________________ FAX NUMBER (____)______________

E-MAIL ADDRESS _______________________________________________________

PROFESSION ___________________________________________________________

STATE/PROFESSIONAL LICENSE NO. _____________________________________

(Please circle) GRADUATE or CANDIDATE of a PSYCHOANALYTIC INSTITUTE

NAME OF PSYCHOANALYTIC INSTITUTE_________________________________

ARE YOU AN INDIVIDUAL MEMBER OF AAPI? (Please circle)          YES           NO

PSYCHOANALYTIC INSTITUTE(S) THAT YOU ARE AFFILIATED WITH (Please indicate if the Institute is an affiliate member of AAPI) _______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Payment Information

Name on MasterCard or Visa _____________________________________________________

VISA or MasterCard (circle which) #__________________________________________________

Expiration Date___________________ 

Signature ________________________________________________________

CONFERENCE REGISTRATION FEES

This annual membership fee covers your membership until June 1, 2004.

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