West Virginia Association of Masters in Psychology · Application for Membership · (Please print clearly within the shaded fields)
Your Name:
	(Last)	(First)	(M.I)
Mailing Address:
(Street)	(City)	(State)	(ZIP)
Employer Name:
Employer Address:
(Street)	(City)	(State)	(ZIP)
Home Phone:		Employer Phone:
Email Address:
Preferred Mailing Address  (please check):		[ ] Home	[ ] Employer
Highest Degree Completed:
Membership Category  (please check):		[ ] Full Member $20.00	[ ] Student $10.00

Please mail completed information along with a check or money order made payable to: W.V.A.M.P. Mail to: Brian Bailey, M.A., Secretary Accord Psychological Services Post Office Box 8475 Huntington, West Virginia 25705 (304) 529-7686 Thank you for your support! Please note that because the West Virginia Association of Masters in Psychology is involved in political advocacy, membership dues are not tax-deductible.