Annual Membership Dues Invoice
July 1, 2006 to June 30, 2007

Name:______________________________________________

Home Address: _____________________________________

City, State, Zip:_____________________________________

Home Phone:__________________ Work Phone:__________

Email Address:____________________________________

Employer:_________________________________________

May we include your name, Email address and work number in an online a membership directory?
( This will be a member-only section of the UASP website.)      Yes      No
Are you willing to help with UASP committee / events?     Yes     No
Would you like to receive e-mails regarding legislation    Yes     No

PLEASE ENROLL ME AS A MEMBER FOR 2006-2007: ___Regular (school psychologist or school psychology trainer) - $50.00
___Associate (for colleagues who are not school psychologists) - $50.00
___Student - $15.00 (may NOT be certified school psychologist & advisor must sign verification below)
___Retired (regular member in past, but now retired and currently not employed as a school psychologist) - $20.00
Make checks payable to UASP

Please complete the form and mail it with your check to the below-listed address:
Mail to: Lynn Durham, Membership Chair
121 Fourth Ave.
SLC, UT 84103
_______    _____________________________    ________________________________
Date   Student Advisor Signature    University

(Students may NOT be certified school psychologists to be student members.)