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Membership Application

To join Psychology Club, one should

be enrolled as a student at Southeast Missouri State University
have an interest in Psychology
pay dues of $5.00 per semester or $8.00 for the entire year

Club Faculty Sponsor: Dr. Rickard A. Sebby, Professor
                                       Office: 427-G Scully
                                       Office Phone: 651-2453
                                       Email: rasebby@semo.edu

To complete your membership application you should

Print this form by clicking within this frame and pressing the "Print" button in your browser and take the printed form to Scully 319 or Scully 404

Membership Dues: If paying by check, please make checks payable to Psychology Club

Please note: Membership is not confirmed until dues are paid.

Your name:

Local Campus Address

Permanent Address (if different than above)

Local Telephone Number

Email address:

Major

Minor(s)

Class Freshman Sophomore Junior Senior Graduate

Anticipated
Graduation Date

Interest(s) in Psychology and how you think the club can be improved:

Your name:
Local Campus Address
Permanent Address (if different than above)
Local Telephone Number
Email address:
Major
Minor(s)
Class	Freshman Sophomore Junior Senior Graduate
Anticipated Graduation Date