APA Division 12 Society of Clinical Psychology Section IX: Assessment

New Members & Membership Renewal Form

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E-mail Address	* For Order Confirmation
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Assessment Applicant/Renewal Details
I wish to apply/ renew Section 9 membership Renew-Membership Apply-For-Membership
APA Member? yes no	Member of Division 12? yes no
Fellow of Division 12? yes no	Current Member of Section IX? yes no
Member of other APA Divisions? yes no	Highest Degree Earned:
Institution Granting Degree:	Department Granting Degree:
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Are you currently a student? yes no	If yes, name of current educational institution:
Dues - Member: Dues $30 - Student Affiliate: Dues $20 Enter dues amount here: Enter additional, optional donation amount to Sec IX here: - Please note that dues payments to Section IX Assessment are tax deductable!: If you wish to pay by check or money order, print this form and mail with your payment (made payable to Divison 12, Section IX Assessment) and send to: Martin Sellbom, Ph.D. Assistant Professor Department of Psychology Box 870348 The University of Alabama Tuscaloosa, AL 35487
If you wish to pay with a credit card, please complete the section below:
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CV2 Number How to find your CV2 number On a Visa or MasterCard, please turn your card over and look in the signature strip. You will find either the entire 16-digit string of your card number, OR just the last 4 digits, followed by a space, followed by a 3-digit number. That 3-digit number is your CV2 number.
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