ADVANCE REGISTRATION FORM
2006 PACIFIC DIVISION MEETING
MARCH 22 - 26, 2006, PORTLAND, OREGON
Fax this form with your credit card payment to Linda Smallbrook (302-831-3372). No cover sheet is needed. Or, if you prefer, mail this form with your payment to Linda Smallbrook, APA, University of Delaware, Newark, DE 19716. Payment must accompany your registration form.
Please print legibly. We use this information for your name badge.
Name: ________________________________________________________________
School Affiliation:________________________________________________________
City: _______________________________State: _______ Zip Code: _____________
Phone: ________________________E-mail: _________________________________
Advance Registration Fees (Received by March 10, 2006 at the National Office)
_____ $10.00 for APA Student Members
_____ $50.00 for APA Regular, International, & Emeritus Members
_____ $60.00 for nonmembers
We will not accept or process any advanced registrations at the National Office past the March 10th deadline. After that date you will need to register on-site in Portland.
Placement Registration
Interviewers should fill out the Placement Interviewers Form. Candidates should check the space below if planning to use the service. Candidates must be a member of the APA in order to use the Placement Service. Placement is a free service for all current APA members.
_____ I will be a job candidate.
___ 1)
Check* (Payable to APA)*The APA can only accept checks drawn on a U.S. bank, in U.S. Dollars.
___ 2) Credit Card Type: (Circle One) VISA / MASTERCARD
Credit Card #:
Exp. Date: / Last 3 Digits on back of card:
Name on Card: _________________________________ Phone #:____________
Signature: _____________________________________ Email: ____________