Note that credit card information will be entered on a secure page after you submit this information.

Dues Payment Form

Membership Dues Type: (Required)
 One year membership dues ($45.00)
 Three year membership dues ($120.00)
 One year graduate student membership dues ($20.00)
 
Last Name: (Required)
 
First Name & Middle Initial: (Required)
 
Email address: (Required)
 
Street or Department Address:

This needs to be your university address. It will be used to update your MPA membership records. You will enter your billing address on the next page.
 
City:
 
State:
 
Zip:
 
Daytime Telephone (Example: 202-336-5555):
 
University Affiliation or Employer:

Warning: mysql_connect() [function.mysql-connect]: Lost connection to MySQL server at 'reading initial communication packet', system error: 111 in /hsphere/local/home/mpaweb/midwesternpsych.org/members/membershippage.php on line 236
Error -- Could not connect to MySQL