Use the following, or go to the PRINTABLE form, print it, fill it out, and mail it to us:

MEMBERSHIP APPLICATION FORM

NETWORK FOR MULTICULTURAL TRAINING, INC.

Membership in NMT is open to individuals and organizations who support the competent practice of multicultural approaches to psychology, broadly defined and other human services which value diversity and respect for difference.

Through Dues, participation in Annual Meetings, Committee work and other voluntary action, Fellows and other Members carry forward the vision which has inspired the Minority Training Program/Center for Multicultural Training In Psychology at Boston Medical Center for more than thirty years. We welcome you to this Network.

NAME: ________________________________________________________________

PROFESSIONAL AFFILIATION AND SPECIAL COMPETENCIES:__________________

LANGUAGES SPOKEN __________________________________________________

ETHNO-CULTURAL IDENTIFICATIONS ___________________________________

________________________________________________________________________

MAILING ADDRESS: ____________________________________________________

TELEPHONES: (W) ; (H) ; (C) (OTHER)

E-MAIL: ________________________________________ FAX __________________

SPONSOR/REFERENCE: (Name, telephone and email) ____________________________

__________________________________________________________________________

ANNUAL DUES (CHECK ONE):

    Fellow (Professional): $100 ____ Organization: $200 _________

    Student: $15 ____ at Institution Name: ___________________________

    Community Member: $25 ____ Affiliation: _______________________

IF FORMER INTERN PLEASE NOTE YEAR(S) AT MTP/CMTP _________________

DUES PLUS VOLUNTARY TAX DEDUCTIBLE CONTRIBUTION ENCLOSED (Please write checks to Network For Multicultural Training, Inc.) $__________________

Please Mail to: NMTP, Inc.

    P.O. Box 39-0714

Cambridge, MA 02139