Association for Autonomous Psychoanalytic Institutes
  

Institute Application for 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 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.)

  

Institute: __________________________________________________________________

Name of Institute
Address: __________________________________________________________________
__________________________________________________________________
City: _____________________________________
State: ___________________________________________ Postal Code:____________
Country: _________________________________________________________________
Year founded: __________________
Institute Phone Number: (______) _______________________________
Institute Fax Number: (______) _______________________________
Institute E-Mail Address: ________________________________________________________________
     
Number of candidates: ______________________ Number of faculty members: ___________________

Number of supervisors:

 ______________________ Total # of institute members: ___________________
Is the institute autonomous (see position statement for definition of autonomous)?
YES   or   NO
Does the institute train mainly mental health professionals?
YES   or   NO
Ratio of mental health professionals/lay candidates: ______________________
     
Representatives:
(Please list two)		 Name: ___________________________________________________________
Telephone: ________________________ Fax: __________________________
e-mail: __________________________________________________________
Name: ___________________________________________________________
Telephone: ________________________ Fax: __________________________
e-mail: __________________________________________________________

  
Membership Fees: Please enclose check in the amount of $350.00, payable to AAPI.

We also accept MasterCard and VISA.
     
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