American Psychology-Law Society
Division 41 of APA
Membership Application/Renewal
{ } New Application { } Renewal Affiliation for Calendar Year: ______ (Please indicate.)DATE______
NAME: ______
first middle initial last
ADDRESS: ______
CITY, STATE, ZIP, COUNTRY: ______
EMAIL: ______PHONE: ______
What is your highest professional degree? BA/BS__ MA/MS__MSW__MLS__JD__PHD___PsyD___EdD__JD&MA__JD&PHD__
Please indicate your major discipline: PSYCHOLOGY_____ PSYCHIATRY______LAW ______OTHER______
Birthyear:______License: yes____ no ____ Graduation Date:______Gender: M______F_____
Employment Type: Full Time______Part-time______Post Doc______NA______
Ethnicity (check one): A (Asian/Pacific Islander)_____ H (Hispanic)_____ N (Native American/Alaskan Native______
B (Black not Hispanic)______W (White, not Hispanic Origin)_____ Other ______
APLS Prior Service: Yes______No______APLS Future Service: Yes ______No______
(Ever served on APLS committee) (Want to serve on APLS committee)
Receive print copy of Law and Human Behavior: yes_____no____
MEMBERSHIP STATUS SOUGHT IN DIVISION 41
_____Member or Associate member of APA (not a student member)
(Send $50.00 for enrollment: Your APA Member #______(PLEASE INCLUDE)
_____Member-at-Large (Psychologist but not a member of APA) - include a vita with your application
(Send $50.00 for enrollment)
_____Member-at-Large (non-psychologist) - include a vita with your application (Send $50.00 for enrollment)
Life Time Member (Over 65 and paid member of Division 41 for at least 30 year [$20.00] per year for enrollment)
Year of enrollment______
EARLY CAREER PROFESSIONALS:
______For those who have received a doctoral degree (J.D., Ph.D., Psy.D., M.D., or Ed.D.) within the past 3 years
[2015, 2016, 2017], send $15.00 for enrollment. Year of Graduation ______.
Indicate whether you are an affiliate of APA (circle one): Yes-_____APA #______No_____
STUDENT MEMBERS: Indicate whether you are a student affiliate of APA - Yes-___ APA#______No___
______Student Member – Undergraduate ____ Graduate_____ or Law Student ______- include proof of student status
(Send $15.00 for enrollment) Expected Year of Graduation: ______
Please list the degree(s) you are seeking and your institution: ______
Make checks payable to: American Psychology Law Society (APLS) (U.S. dollars only) and mail to:
Kathy Gaskey, Administrative Assistant
American Psychology-Law Society email: /
Division 41 of APA Tel: (704) 456-7276
PO Box 805 Fax: (704) 456-7276
Harrisburg, NC 28075 www.apadivisions.org/division-41/index.aspx
Credit Card payments can be made on-line. Log on to www.apadivisions.org/division-41/index.aspx for instructions. For credit card payments off-line, please enter the requisite information:
Credit Card Number:______Exp:______
Name on Card: ______Signature:______Security Code (back of card):______
Affiliation is based on the calendar year, but applications can be submitted any time.
Membership collection: August 1 – July 31. Any monies collected after August 1 will be applied to the following year’s membership.
If your application is for the current year, your affiliation will be dated January 1st of this year.
If your application is for the next calendar year, membership will begin January 1. Your subscriptions will also begin with the first issue after January 1.