Membership Application | Eastern Psychological Association

Graduate Student Application

Membership Dues

Your Dues Rate Type is: Graduate Student $55.00

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Affiliation (School or Employer)

Address Line 1 *

Address Line 2

Address Line 3

City *

State

Zip Code *

Country

Website

Phone Number *

Fax Number

CC Email

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Any individual, including a life member, can make a charitable contribution to the EPA Foundation, which supports our activities. A cumulative contibution (made over several years) of $500 or more is recognized on the Founders page of the EPA program.

Foundation donation

If you would like to contribute to a travel fund that assists other student members to attend the annual conference, you may do so here. Choose whatever amount is comfortable for you. The total amount in this fund will be disbursed annually. Thank you.

Sponsor of student travel

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing Eastern Psychological Association to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Eastern Psychological Association, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Total Amount Due

Graduate Student Application

Membership Dues

Contact Information Contact Information

Payment Details Payment Details

Contact Information

Payment Details