Note: there is also a printable membership form if you prefer.

Membership Form

Last Name: (Required)

First Name & Middle Initial: (Required)

Mailing Address (preferably an academic or business address): (Required)

City: (Required)

State:

Zip: (Required)

Daytime Telephone (Example: 202-336-5555): (Recommended)

University Affiliation: (if applicable)

If Other, please specify

Employer

Email address: (Required)

Academic Record (degrees and dates): (Required)

Professional Record (Employment History, if applicable, dates and positions): (Required)

Are you currently a graduate student?: (Required)

Yes
No

Membership Type (Graduate students must be endorsed by a regular MPA member. Undergraduates are not eligible to become members of MPA.): (Required)

Regular Member
Graduate Student

Note: Graduate students, please enter the name and email address of your endorser. Please note, however, that YOU are responsible for contacting them and asking them to email us indicating that they endorse your application. Our email address is secretary@midwesternpsych.org.

Endorser's Name:
Endorser's Email Address:

Date:
Applicant's Signature (Typing your name constitutes your legal signature)