ASSOCIATION for AUTONOMOUS PSYCHOANALYTIC INSTITUTES

RESISTANCE TO CHANGE IN PSYCHOANALYSIS:
INTEGRATING TOOLS FROM RESEARCH INTO PSYCHOANALYSIS

(Please print or type.)

LAST NAME ________________________________________  DEGREE(S)____________________

FIRST NAME _____________________________________ MIDDLE INITIAL __________________

ADDRESS ________________________________________________________________________

CITY _________________________________________ STATE _____________________________

ZIP/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_____________________________________________

INDIVIDUAL MEMBER OF AAPI?                    (Please circle)          YES           NO

□   Check here if you wish to become an INDIVIDUAL MEMBER of AAPI.

PLEASE enclose the following membership fee and select the AAPI Individual Member fee for your conference Registration:

This annual membership fee covers your membership until June 1, 2007.

PSYCHOANALYTIC INSTITUTES YOU ARE AFFILIATED WITH:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Payment Information

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.

Name on Credit Card: ___________________________________________________________

Card Number: _________________________________________________________________

Expiration Date_______________________ 

Signature ____________________________________________________________________

CONFERENCE REGISTRATION FEES

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