Affiliate Membership Form


AMERICAN COLLEGE OF PROFESSIONAL NEUROPSYCHOLOGY

Application for Affiliate Membership

 

Name:  _________________________________________________________________ 

Degree:  _________            Degree Granting Institution:  _________________________

Institutional Affiliation (if any):  _____________________________________________

Private Practice:   Yes     No   (circle one)

Address for Contact and Journal Delivery:

              ________________________________________________________

             ________________________________________________________

             ________________________________________________________

             ________________________________________________________

Phone Number for Contact:    _______________________________________________

E-mail for Contact:   ______________________________________________________

 

*Affiliate membership benefits include:

·         Subscription to:  Applied Neuropsychology-Adult (AN-A) & Applied Neuropsychology-Child (AN-C)

·         Access to the ACPNTalk Listserve

·         Discounted fees to meetings and workshops

·         APA CE credit for workshop participation and other planned activities

 

Associate membership does not include listing in the ACPN directory or any implied board certification status, voting privileges, or review or examination activities.

The annual dues for affiliate membership is $75 for Professionals, $35 for students and postdocs..

There are several payment options available:

_____ Mail this form & check payable to "ABN" or “American Board of Professional Neuropsychology” to

        
Thomas Bristow, Psy.D. 
 ABN Treasurer 
 PO BOX 634 
 Wheeling, IL 60090
 

_____ Fax this form with your credit card information to 855-791-1651.

            Card (please circle): Visa     Mastercard     Am Ex     Discover

            Card number: ____________________________________

            Expiration Date: ______________________ Security Code (on back): _________________

 

_____ Mail this form with credit card information to the above address.

            Card (please circle): Visa     Mastercard     Am Ex     Discover

            Card number: ____________________________________

            Expiration Date: ______________________ Security Code (on back): _________________

 

_____ Fax this form to (855)791-1651 and pay via PayPal (account is abn.treasurer@gmail.com).