Manhattan Psychological Association, Inc.

www.cyberpsych.org/mpa/
James L. Rebeta, Ph.D., President

WINTER 2007 Workshop:

“Cognitive Behavior Therapy for Chronic Worriers”
Workshop Registration Form

Please print or type all information

First Name: ___________________ Last Name: _______________________________
Degree: ______________________ Profession: _________________________________
How did you hear about the workshop: ________________________________________
MAILING ADDRESS: (please circle one) HOME OFFICE
__________________________________________________
__________________________________________________
__________________________________________________
TELEPHONE/E-MAIL CONTACT:
Home: _________________________ Office: _______________________
E-Mail: _____________________________

WORKSHOP FEES: (circle which applies to you)
FREE to all current MPA members (2007 dues paid)
$35 for non-members
$15 for students (with ID)

Please make checks payable to the “Manhattan Psychological Association” and mail with this form to register for the workshop.
MAIL TO:
Manhattan Psychological Association
c/o James Rebeta, Ph.D.
450 East 63rd Street # 6B
New York, NY 10021-7930
OR, if 2007 dues are paid, form can be e-mailed to: jlr2001@med.cornell.edu