Section V - Membership

Section V: Psychologist-Psychoanalyst Clinicians
Division of Psychoanalysis (39)
American Psychological Association

Application for Membership in Section V

Please Print

Name
Degree	Diplomate
Home Address
City	State Zip
Phone
Fax
Office Address
City	State Zip
Phone
Fax
2nd Office Address
City	State Zip
Phone
Fax
E-mail
Cell Phone
Pager
Preferred Mailing Address	Home Office 2nd Office

You must be a member of Division 39 in order to become a member of Section V. Click here to join Division 39.

I am a member in good standing of Division 39 of the American Psychological Association, and I wish to apply for membership in Section V of the Division.

Signature: _______________________________________

Date: _____________________

Please print this form and enclose your check for $60. made payable to:
Section V - Psychologist-Psychoanalyst Clinicians, and remit to:
Administrator for Section V
333 West 57th Street, Suite #103
New York, NY 10019-3115
Questions? Please contact
David Lichtenstein, Chair, Membership Committee
(212) 929-6208, dlichtenstein@gmail.com