Membership Application Form
 
I wish to be a   Member  ($120)      Associate  ($120)      Student Affiliate ($32)
  New Doctoral Graduate ($60)      2nd-Year Doctoral Graduate ($85)
  (Click here to see a description of the classes of membership.)
 
NAME: First Middle: Last:
GENDER : Male    Female
DATE OF BIRTH:
DEGREE:
PREFERRED MAILING ADDRESS (Home or Business)
This listing will also be in the on line membership directory unless you complete the next  section.)
Street:
City:   State:   Zip+4:
Country:
PREFERRED DIRECTORY ADDRESS: (If different from your mailing address)
    Do Not Include in Directory
Street:
City:   State:   Zip+4:
Country:
 
PHONE: Work:        Home:       Home Phone Unlisted     
              Fax:
EMAIL:          Email Unlisted 
           
 
PROFESSIONAL STATUS:  Graduate Student    Professional
EDUCATION: (Graduate students indicate undergraduate school and current graduate school information.)
Degree    Year      Institution    Major Field of Study
OCCUPATIONAL CATEGORY/SPECIALTY AREAS:xx
(Graduate students indicate area of study:
and degree toward which you are working: )
Primary Assessment Activities:
Clinical Practice     Teaching     Research     I/O or Consulting     Other
Primary Populations Served:
Infant     Child     Adolescent     Adult     Geriatric     Family     Couples/Marital
Primary Assessment Instruments:
MCMI-III     MMPI-2     NEO-PI-R/FFM     Neuropsychological     PAI     Rorschach    
TAT      Other  
Primary Assessment Specialty Areas: (Check no more than 5)
Personality I Q/Achievement LD/ADHD/Gifted
Collaborative/Therapeutic Disability Employment/Career
Cross Cultural Psychometrics Trauma
Law Enforcement Consultation to Therapists Consultation to Assessors
Neuropsychological Executive Coaching Forensic (type)
Other   
MEMBERSHIP: (Professional societies, certificates, licenses)
APA     Div 5     Div 12     Div 40     Div 41     Div 42     Other
State Psych Assoc     Regional Psych Assoc     INS     NAN     APS    
Other
TRAINING AND EXPERIENCE IN PERSONALITY ASSESSMENT:
 
I wish to receive the Exchange newsletter electronically.    
I certify the information provided above is accurate and correct.    
Membership fee   $
 Please sign me up for membership in the International Society for Rorschach and
 Projective Methods. ($35)
  $
  Total amount to be billed my credit card   $