APA Community College Teacher Affiliate Application

Community College Teacher Affiliate Application

Please read Community College Teacher Affiliate Application Instructions before completing this application.

Applicant Information

(*Required field)

Prefix	First*	Middle	Last*	Suffix

Name: *

Country:*

Address: *

City:*

State/Province:*

Zip/Postal Code:*

Email:*

Please reenter Email for verification:*

Name of School:*

Date of birth:*

(MM/DD/YYYY)

Gender:*

Male Female Transgender

We require either a work phone number or a home phone number to facilitate follow-up:*
e.g., (123) 123-4567 or +1 123 456 4567

Work Phone:

Ext:

Home Phone:

Fax:

Your affiliation with APA is considered part of the public record. Your contact information will be listed in the APA Membership Directory. If you wish to publish only your name in the directory, please check here.

Community College Teacher Affiliate Fee

Affiliate Fee

$50.00

I understand the affiliate fee is required whether or not I order journals.

Indicate your agreement:* Yes No