Dallas Group Psychotherapy Society P.O. Box 803227,  Dallas, TX  75380-3227   MEMBERSHIP APPLICATION FORM FOR MEMBERSHIP YEAR:  FEB 06 - FEB 07 Print Response to All Items   NAME_____________________________________________________________________ DATE_______________   MAILING ADDRESS______________________________________________________________________________   CITY______________________________________STATE______________ZIP______________________________   PHONES: HOME______________________WORK________________________FAX_________________________   EMAIL___________________________________________PLEASE CIRCLE PREFERRED METHOD OF CONTACT   SS#__________________________ LICENSE(S) and #(S) ______________________________________________   AGPA MEMBER?     NO   or   IF YES:     CLINICAL       FELLOW      ASSOCIATE      AFFILIATE    ARE YOU A CGP?     YES       NO                               PRIVATE PRACTICE?     YES        NO            COLLEGE ATTENDED____________________________________________DEGREE_____DEGREE YEAR______   EMPLOYER____________________________________________________________________________________   AREAS OF SPECIALIZATION/EXPERTISE:  1) ________________________________________________________ 2) ___________________________________________________3 ________________________________________ TYPES OF GROUPS YOU LEAD: 1) ________________________________________________________________ 2) _____________________________________________3) _____________________________________________   ARE YOU INTERESTED IN BEING A PRESENTER AT ONE OF OUR PROGRAMS?   YES    NO   REFERENCES:  LIST THREE 1) _______________________________2) _______________________________3) __________________________   MAIL PAYMENT (CHECK, VISA OR MC) FOR DUES & THIS FORM TO: DGPS, PO BOX 803227, Dallas, TX 75380-3227   MEMBERSHIP CATEGORIES Clinical, Fellow, Associate and Affiliate Members ..$60                                         Student Members (include copy of student ID) ...$25                                             Life Members & Significant Other Members . $30                                           Agency Membership (allows all recorded staff of an agency to participate at Member rates)...$350   I HAVE ENCLOSED A CHECK IN THE AMOUNT OF $_______________Check #____________Date_____________   CHARGE MY:   VISA          MC           ACCOUNT #____________________________________EXPIRES__________   PRINT NAME____________________________________SIGNATURE_____________________________________   PLEASE INDICATE IF THERE IS INFORMATION THAT YOU WOULD NOT LIKE LISTED IN THE DIRECTORY OR IN THE WEBSITE DIRECTORY