PHILADELPHIA NEUROPSYCHOLOGY SOCIETY

JOIN Print or download and mail. Download here: PNSMemApplication2011.pdf Membership Application for 2011 1. Contact Information Name, Highest Degree:______________________________________________ Mailing Address: ___________________________________________________ City, State, Zip: ___________________________________________________ Phone, Fax: _____________________________________________ E-mail Address: __________________________________________ 2. Membership Status: ______$90 Members* ______$65 Post-Docs* ______$35 Students* *All memberships include electronic subscription to Neuropsychology and reduced symposia admission. 3. Donation for Scholarship Initiative Do you wish to make a donation to PNS' new "scholarship initiative" to fund scholarships for graduate student awards (please include donation with dues check)? Y / N $___________ 4. Application & Payment Please mail this application and check (made out to PNS) to: Lynn DellaPietra, PhD PNS Treasurer 4930 Osage Ave Philadelphia, PA 19143 5. Brief Member Survey (optional) a. Are you a first time member-applicant to PNS? Y / N b. List your preferred times (e.g., Wednesdays or Thursdays, 5PM), for PNS monthly meetings (these are usually 1 hour-long presentations by local speakers): ___________________________________________________________________ c. List your preferred times (e.g., Fridays but not Saturdays) for PNS symposia (these are usually day-long or half-day-long presentations by speakers from across the US: ___________________________________________________________________ d. List speakers or topics of interest to you for monthly meetings and/or symposia: ___________________________________________________________________ ___________________________________________________________________ e. How could PNS change to better meet your needs as a neuropsychologist/psychology student (please use the back of this page if you need extra space)? ___________________________________________________________________ ___________________________________________________________________ THANK YOU! JOIN_files/PNSMemApplication2011.pdfshapeimage_1_link_0

Join by filling in this form and paying with Paypal (see box below). The downloadable form at bottom is currently out of date... updated form will be available as soon as possible.