Please indicate your membership category, fill in name & address information, and include a check for annual dues and anticipated CPE credit of $15.00 payable to PNNS. Membership cannot be accepted without accompanying dues payment.
__ MEMBER (eligibility: doctorate level psychologist whose primary interest, focus and professional commitment is to either neuropsychological education, research, or clinical practice).
__ ASSOCIATE MEMBER (eligibility: all other persons, psychologists, speech pathologists, occupational therapists, neurologists, etc., with an interest in neuropsychology).
Last Name _______________________ Ph.D./Psy.D./M.A. First Name ______________
Address (Preferably Work) __________________________________________________
_____________________________________________________________________
City ______________________________________ State _____ Zip _________________
Home Phone (______) _________________ Work Phone (______) __________________
Fax (______) __________ Cellular Phone (______) __________Email________________
List Work Phone/Address in Website Directory (PNNS.Org)? Yes____ No____
Send Monthly Presentation Announcements by: Email____ Regular Mail____
Survey: list topics you would like discussed at our monthly meetings and indicate with a check those for which you might give a clinical/research presentation. Check
Topics: ________________________________________________________________ ___
________________________________________________________________ ___
Return with $15 dues-check, payable to PNNS, to:
PNNS, c/o Brad Powell, PhD
1800 Cooper Point Road SW, Bldg.17
Olympia, WA 98502
For questions or comments please contact Brad Powell, (360) 491-1705 or
bradpowell2@comcast.net