MEMBERSHIP:

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Registration form

Personal information

First name*

Last Name*

Email address*

Please make sure to use your active email address

Cell phone

Country

Profession*

Academic Affiliation

Other Academic Affiliation

Student?

Yes

Degree

Postgraduate

Graduate

Undergraduate

Psychoanalytic Candidate/Trainee?

Yes

Retired?

Yes

Registration type

IPhA MEMBERSHIP ONLY (regular, 1-year) - $50

IPhA MEMBERSHIP ONLY (reduced rate*, 1-year) - $30

IPhA MEMBERSHIP ONLY (undergraduate, 1-year) - $10

ADD ME TO IPhA MAILING LIST - free

Total Registration Cost

$ 0

Payment Method*

Paypal or Credit Card

Pay with a Check

Pay through PayPal

You will be redirected to PayPal checkout page once you submit. After you complete your payment, you will be redirected back to our site with a confirmation.

Pay with a Check

Please send the checks or money orders (payable to IPA) to Denis O'Keefe, 142A Main St., Highland Falls, NY 10928-1520; IMPORTANT--If you pay by check, notify Brian D'Agostino by email at

We have received your request

Thank you %FNAME%
You successfully registered to the event.

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