CENTRAL 2007

CENTRAL 2007

ADVANCE REGISTRATION FORM

APRIL 18-21, 2007, THE PALMER HOUSE HILTON, CHICAGO, IL

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. This information is used for your name badge.

Name:

Affiliation:

Email:________________________________________________________________

Advance Registration Fees (Received by March 28, 2007 at the National Office)

$10.00 APA Student Members

$50.00 APA Regular, International & Emeritus Members

$60.00 Nonmembers

We cannot process any advanced registrations at the National Office past the
March 21^st deadline. After that date you will need to register in Chicago.

Placement Registration

Interviewers should also complete the Placement Registration 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) Visa MasterCard Exp. Date

Last 3 digits on back of card

Name as it appears on Card:

Signature of Authorization:

Email: Phone #: