Applicant Information:
First Name: 
Last Name : 
Organization: 
Address: 
Address (continued) : 
City: 
State: 
Zip/Postal Code : 
County: 
Home Phone:
Email: 
Website URL: 
Professional Information:
Employer :
Address:
Work Phone:
Fax:
Title:
Highest Level of Degree:
School:
Title of Dissertation:
Currently in Private Practice?
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Are You Licensed?
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Area(s) of Expertise Includes:
Area(s) of Interest Include:
Send Mail to:
 Home Office
Do you want to be
listed in the LPANJ
Membership Directory?:
 Yes No
Do you want to be included
in an internet listserve?:
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Select Membership Level:
FULL MEMBER: Any individual who possesses a bachelors, masters or doctoral degree in
psychology and is committed to advancing the field of Latino psychology. Full Members
may vote on all matters and hold certain offices. Doctoral-level members and master-level
members with three years of board experience may serve as president-elect, president or
past-president.
Annual dues: $60
AFFILIATE: Any individual who is committed to advancing the field of Latino psychology,
but who does not meet the requirements for Full Membership (e.g., social work, counseling,
psychiatry, nursing). Affiliate members enjoy all the benefits of full membership; however
they may neither vote nor hold office, but may serve on committees.
Annual dues: $40

STUDENT: Any individual currently enrolled in an undergraduate or graduate program in
psychology or a related discipline and who is committed to advancing the field of Latino
psychology. Undergraduate student members may neither vote nor hold office, but may serve
on committees, while graduate students may vote and hold certain offices.
Annual dues: $25

I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS MADE BY ME ARE TRUE.