Society for the History of Psychology

Division 26 of the American Psychological Association

---

Membership Form

APA ID# 0 0 0 0-__ __ __ __-__ __ __ __

Title (MR., MS., DR.) ___

Name (First) ____________________________ _  (MI)___

Name (Last) ____________________________________

Address _____________________________________

____________________________________________

____________________________________________

____________________________________________

State/Province ____     Zip/Postal Code _______________

Country _______________________

E-mail Address _________________________

Membership Category:

__APA Member ($35.00)   __   Student Affiliate ($24.50)  

__ Member of Another History-Related Organization  ($35.00)

__ Dues exempt member of APA ($24.50)

Principal interests _______________________________________________________

Secondary interests _______________________________________________________

Payment information
This form should be sent with check or money order payable to APA Division 26 in  U.S. dollars 
or Charge (circle one)          VISA           MasterCard

Cardholder Name:_________________________________________________________

Card No. ________________________________________

Expiration Date: _________________

Signature (Required)__________________________________

Credit Card Billing Address (if different from above)

__________________________________________

__________________________________________

__________________________________________

Send to:

Division 26 Administrative Office
American Psychological Association
750 First Street, NE
Washington , DC 20002-4242
USA

For additional information, contact the SHP Membership Chair, Katharine Milar at kathym@earlham.edu