ASGPP Membership Application

Please complete and submit this form Online to the national office. You will be charged a credit card fee of 2.2% + $0.30. If you prefer to pay by check print this form and mail with payment to: ASGPP 301 N. Harrison Street, Suite 508, Princeton, NJ 08540 USA.

Name:

Degrees:

Licenses/Certifications:   Present Occupation:

Affiliation/title ONLY IF used in address:

Address:   City:

State:       Zip:               Country:

Phone:   Fax:   E-mail:

Type of Membership:
Regular (yearly membership dues -$120)
Retiree (yearly dues - $60)
Student(yearly dues - $60)*
* Students must be matriculating in an accredited college/university and carrying a minimum load of 9 credits and/or pursuing a full-time residency or internship. Students must submit a photocopy of college/university picture identification.

 I am from a country other than US, Canada or Mexico (additional $10 to cover mailing costs).

 I would like a membership certificate (additional $15 )

How did you hear about the ASGPP? Mailer Online Trainer/Teacher Ad in publication Colleague/Friend

ASGPP member who encouraged you to join (if applicable):

THIS IS A RENEWAL

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