Founded 1976	ALASKA SCHOOL PSYCHOLOGISTS ASSOCIATION Membership Application 10/2007-10/2008

Name________________________________________ MAKE CHECK PAYABLE TO ASPA

Home Address_____________________________ AND RETURN TO:

City____________ State____ Zip________ Jason Stahl, ASPA Treasurer

Mailing Address_________________________3520 Checkmate Drive

City___________ State_____ Zip__________ Anchorage,AK 99508

Residence Phone_____________________________

Work Phone_______________________

FAX________________________ Email___________________________________________

Please indicate the basis upon which you qualify for membership:

_______A. A Member is a person who is currently certified as a School Psychologist. Has paid current membership dues.

Dues for one year....................................................$40.00

_______B. A Student is a person who is studying toward School Psychologist certification. Has paid current (one-half) membership dues.

Dues for one year....................................................$20.00

Verification of status must accompany the original application for membership. Such verification would be:

A) Member: Copy of State Certificate

B) Student: Letter of current student status from the Dean or Department Head (required annually).

I certify that the designation of my professional status on this form is true.

SIGNATURE_____________________________

DATE_________________

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