LOS ANGELES COUNTY PSYCHOLOGICAL ASSOCIATION
September 1, 2008 - August 31, 2009 MEMBERSHIP DUES

*=Mandatory Field

MEMBERSHIP CATEGORY
Application must be at the highest level for which the person is qualified.
Full Member
Doctorate or licensed in psychology
$195
Pre-Licensure Full Member
Doctorate in psychology, working toward PSY licensure, maximum 3 years at this level
$100
Newly Licensed Full Member
Licensed less than three years as of 9/07, maximum 3 years at this level
$120
First Time Full Member
Doctorate or licensure in psychology joining LACPA for the first time
$120
Associate Member
Terminal Master's in psychology
$120
Affiliate Member
Other professional wishing to support LACPA activities
$120
Emeritus Member
LACPA member for at least 15 yrs. and age 70 or older
$65
Disabled Member
Fully disabled and unable to work
$65
Out-of-County/State Member
Lives and works out of Los Angeles County
$105
Student Member
(Pre-Doctoral, must submit proof of current student status to: lacpsych@aol.com)
$35
MEMBERSHIP TOTAL:
Keep me on/Add me to the LACPA Listserve (FREE with membership)
Sign me up for the Annual Wine & Cheese Party, September 14, 2008 (FREE with membership)
Sign me up for the APAIT Risk Management Program on January 17, 2009 ($125 with membership)
$125
OPTIONAL
New Online Directory Listing on LACPA Website
 $50
Renew Online Directory listing by 9/30/08 and save $5
 $45
LACPA Foundation Support. Donation Amount:
CA Psychological Association Political Action Committee (CPA-PAC).
Donation Amount:
For a PAC donation, the law requires that you state your employer or indicate if self-employed:
OPTIONALS TOTAL:
TOTAL AMOUNT AUTHORIZED*:
Add up Membership Total and Optionals Total. Enter Grand Total here:
GENERAL INFORMATION
Name*:
 Degree:
Business Address:
 Suite:
City:
State/Zip:
/
Business Phone
 Fax:
Email:
(Must provide if on LACPA's Listserve)
CA Psychologist License No.:
Home Address: Apt#.
Home City: Home State/Zip: /
Home Phone:    
Preferred Mailing Address*: Office     Home
PAYMENT INFORMATION
Visa/Mastercard No.:
(No American Express) 
Exp. Date:
Name on Card:
Security number:
(last 3 digits on the back of credit card)

Checks are also accepted: Please fill out the above form and leave the credit card section blank and click the submit button below. Then write your check for the total amount, make it payable to LACPA and mail it to the address below:

Select this checkbox if paying by check.

LACPA
17277 Ventura Boulevard, Suite 202
Encino, California 91316
PROFESSIONAL ETHICS DECLARATION*
 I have read and agree to abide by the Code of Ethics of the California Psychological Association (identical to the Code of Ethics of the American Psychological Association).
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17277 Ventura Boulevard, Suite 202 • Encino, California 91316
(818) 905-0410 • FAX (818) 906-3845
Contact LACPA