Membership Application | Eastern Psychological Association

President's Circle

Membership Dues

Fee to join initially: $400.00

Your Dues Rate Type is: President's circle $100.00

Contact Information

Email *

Confirm email address *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country

Website

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
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Include me in Broadcast Email *
Yes No

Payment Details

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

President's Circle

Membership Dues

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Contact Information

Payment Details