ASSOCIATION for AUTONOMOUS PSYCHOANALYTIC INSTITUTES
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ASSOCIATION for AUTONOMOUS PSYCHOANALYTIC INSTITUTES
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The Fourth Annual Conference of AAPI 2004 CONFERENCE REGISTRATION FORM The Implicit and Explicit Domains in Psychoanalytic 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 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)
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Payment InformationName 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, 2005. We welcome all graduate psychoanalysts and psychoanalytic candidates—do join us! | ||||||||||||||||||||||||||||||||||||||||
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