Tampa Bay Psychoanalytic Society
Membership Application/Renewal Form

Two easy renewal methods! You may apply/renew membership by :

Online Application/Renewal
1.Type your information in the spaces provided below
2. Click on the "Submit" button at the bottom of the form
3. Mail check for payment of dues to address noted at the bottom of the form.
or
Mail Renewal
1. Print the completed form
2. Mail the form along with your membership dues payment to the address noted at the bottom of
this page.
MI
No
No
No
Do you provide services for:
(check all that apply)
*Note: Home Addresses/phone numbers will not be included in the Directory unless requested.
         Payment of dues required by October 1st for inclusion in the Print Directory.
         Membership not active until dues are received by mail.
         *Please include your current email address*

Mailing Address for payment:   Lynne Wadsworth, Administrative Assistant
                                                 Tampa Bay Psychoanalytic Society
                                                          1913 Dockside Drive
                                                       Valrico, Florida 33594
Last Name
 First
Degree
 License #/ Discipline
Home Address
City
 State
 Zip
Office Address
City
 State
 Zip
Office Phone
 Home Phone
 Fax
Preferred Mailing Address: HOME
 OFFICE
 Email Address*
Inclusion In Print Directory?
 Yes
 Inclusion In Web Directory?
 Yes
Accepting Referrals?
 Yes
 Membership Category
Children
 Adolescents
 Adults
 Couples
 Family
Practice Specialties/Services (please list)
Additional Comments/Questions