Oklahoma School Psychological Association	a NASP affiliate
2007-2008 MEMBERSHIP FORM (July 1 - June 30)

This is the printable form for membership registration. Fill in the items, then press the Print This Page button at the end.  To start over, press the Clear Form button. Click on Close This Window to return to the OSPA website.

Fields marked with an asterisk * are required - enter NA if information is unavailable.

*First Name	*Last Name
*Address line 1	(please list the address where you wish to receive mailings)
Address line 2
*City	*State   *ZIP
*County	*Gender Male Female
*Home Phone	*Work Phone   *Fax
E-mail	*Birthdate mm/dd/yy
Certifications	School Psychologist     Psychometrist     NCSP Certification
Other Credentials	NASP Member
*Current Position   *Employer
Do not publish my information in the OSPA directory.    I am interested in sponsoring a school psychologist intern. Do not make my name available to profession related vendors.
Regular -$50	Certified school psychologist or psychometrist
Student -$25	Student members must be enrolled at least half-time in school psychology program and not employed full-time in the profession. Please include Supervisor/Advisor signature below. Signature of Supervisor/Advisor
Life -$25	Retired school psychologist or psychometrist
Associate -$30	Not certified as a school psychologist or Psychometrist, but work in a related field
Please complete and return with dues payment to: OSPA    PO Box 665    Jenks, OK 74037 For Office Use Only Date Entered:________________ Check No:___________________ Amount: ____________________