Membership Submission

Member Information:

Name: Anthony Bergamin
Home: Business: Cell: 647-654-3645 Mailing Address:
[88] Is this a New Member Application or a Membership Renewal? Membership Renewal

Membership Level:

Professional - $85 Inactive - Student - Associate Expressive Arts Practitioner (AEAP) - Supporting - Affiliate - International -

Membership Questionnaire

Name of Company, Agency or Employer: self-employed private exat practice
Phone number:

Name of Current Supervisor: Shelane Donoghue, RP
Supervisors Phone:

Offering Supervision? No, I do not offer Supervision at this time

CRPO Registered Psychotherapist: No, I do not yet have CRPO RP Designation

Committee Work? Yes, I am interested in committee work
Committee: Communications
OEATA Directory Listing: Yes, I have completed the OEATA Public online directory form

Application Materials:

Completed renewal form - please include a printed copy of this form with your application materials, Payment via cheque, Money order, or Paypal transaction
I'm a student:
Signature: YES Donation: TOTAL: 85