Manhattan Psychological Association

2013 Annual Dues Statement
Please Print and mail


Full Members/Associates:   
If received or post-marked by December 31, 2012:            $55
If received or post-marked after December 31, 2012:         $65

1st Year Members / Associates:                                     $35

Students (Provide Copy of School ID):                             $15
           
                                  Voluntary Contribution:        ___________   

                                         Total Enclosed:             ___________          


Name:         _________________________________________

Degree:       __________

Address:     _________________________________________

                   _________________________________________
       
                   Is this your HOME or OFFICE address (circle one)?

E-mail Address:  _______________________________________

Phone: (H)     __________________________________________

            (W)     __________________________________________

          (Cell)    __________________________________________

          (Fax)     __________________________________________

Are you a current NYSPA member? (please circle)   Yes        No

Suggestions for Future Speakers/Topics:

                         _________________________________________

Please submit your completed nomination ballot, renewal form, and

check made payable to Manhattan Psychological Association to:

James L. Rebeta, PhD, President, MPA

450 E. 63rd Street, Apt 6B

New York, NY 10065-7930

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