Name:
Home Address:
City, State, Zip:
Present Employment:
Business Address:
City, State, Zip:
Telephone (Home):
Telephone (Business):
Fax:
Email:
Re-enter Email:
Please send mail to my	which location home address business address
How did you hear about NSGP?	How did you hear about NSGP? Colleague Supervisor NSGP Conference NSGP Website Email advertisement Newspaper advertisement Friend Other
Are you an AGPA member?:	AGPA Member? No, I am not an AGPA Member Yes, I am currently a Clinical Member Yes, I am currently an Associate Clinical Member I have applied to become a Clinical Member I have applied to become an Associate Clinical Member
Applying for:	Membership Type Clinical Member Associate Clinical Member Affiliate Member Student Member
Classes of Membership Clinical Member: Clinical professionals who are Fellows or Clinical Members in good standing ‎of the American Group Psychotherapy Association or who are currently members in good ‎standing in the National Registry of Certified Group Psychotherapists or who meet the ‎requirements to be Clinical Members of the American Group Psychotherapy Association or ‎Members of the National Registry of Certified Group Psychotherapists. Associate Clinical Member: Clinical professionals who are Associate Clinical Members in good ‎standing of the American Group Psychotherapy Association.‎ Affiliate Member: Clinical professionals in the field of mental health who, although not Clinical ‎Members or Associate Clinical Members of the American Group Psychotherapy Associations, ‎are interested in the practice and development of group psychotherapy.‎ Student Member: Individuals currently in training in recognized graduate programs in the field ‎of mental health. This membership category is held on a year to year basis pending the ‎conferring of a degree in one of the mental health professions and requires substantiation of ‎student status annually.‎
Professional Education:
Professional experience in group psychotherapy:	Please outline your professional experience with group psychotherapy.
References: Give name, address and phone number of two people in the mental health field who we may contact regarding your application.
Dues Payment:	For paying full Annual Dues Life Member (No dues owed) .............................. $0 Clinical Member ...................................................... $130 Associate Clinical Member ................................. $125 Affiliate Member ...................................................... $110 Student Member ..................................................... $25
	For Pro-rated Dues, when joining in Jan, Feb, March or April (2/3 Rate) Clinical Member (2/3 Rate) ...................................................... $87 Associate Clinical Member (2/3 Rate) ................................. $83 Affiliate Member (2/3 Rate) ...................................................... $73 Student Member (2/3 Rate) ...................................................... $25
	For Pro-rated Dues, when joining in May or June (1/3 Rate) Clinical Member (1/3 Rate) ...................................................... $43 Associate Clinical Member (1/3 Rate) ................................. $42 Affiliate Member (1/3 Rate) ...................................................... $37 Student Member (1/3 Rate) ..................................................... $25
	BEFORE hitting the Submit button below, please REMEMBER YOUR FEE above. You will need to enter this on the payment page.