Association for Autonomous Psychoanalytic Institutes
  

Application for Individual Membership

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: __________________________________________________________________
Office Phone Number: (______) _______________________________
Office Fax Number: (______) _______________________________
Home Phone Number: (______) _______________________________
E-Mail Address: __________________________________________________________________

Education
Highest Degree: ___________ Institution: _____________________________________________

Psychoanalytic Training
Year: ___________ Place: ________________________________________________
Certification (or Graduation) Year: ___________
  
Of which affiliate psychoanalytic institute are you a member (i.e., alumna/us, supervisor, faculty and/or member?
  		 __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
What other psychoanalytic institutes are you a member of? __________________________________________________________________
__________________________________________________________________

  
Membership Fees: Graduated (or Certified) Psychoanalyst: $75
Psychoanalytic Candidate: $35
     
Name on MasterCard/VISA: __________________________________________________________________
MasterCard/VISA Number: _________________________________________ Exp. Date: _______________
     
Signature: __________________________________________________________________
           
 

Send this Form with Payment to: AAPI

1800 Fairburn Ave., #201
Los Angeles, CA 90025
Attn: J. Legg

Tel: (310) 396-2636
Fax: (310) 396-2636
Email: info@aapionline.org