Arizona Neuropsychological Society
Student Membership Application

Complete and submit this form and pay via PayPal (with a PayPal account or credit card). If you have questions or need assistance, please email admin@az-ns.org.

Note: Bolded Fields must be completed for the form to submit.

YOUR NAME (First, Last)
 

UNIVERSITY/DATE OF GRADUATION
  (enter like "YYYY")

DEGREE/MAJOR

AREA OF SPECIALIZATION

HOME ADDRESS
  City: State: Zip:

HOME PHONE/CELL
 /  (Please include area codes)

EMAIL ADDRESS

(To conserve resources, we intend to communicate with you primarily by e-mail.)

Check this box if you DO NOT wish to have your name and email address listed in the Membership Directory

ATTESTATION BY APPLICANT:
By checking this box, you agree that to the best of your knowledge, the information which you have provided in this application is accurate and truthful. You hereby agree to receive electronic communication.

I am applying for membership as a Student Member ($20.00/year).