I would like to pay:

Cheque US $ or GBP (payable to the Journal of Analytical Psychology)

Credit/ Debit Card. An extra 3% will be charged if paying by credit card.

Visa

Mastercard

Maestro

American Express

Card Number:

Card valid from:

Card Expiry date:

Issue Number (3 digits at the back):

Name:

Address:

Post code:

Telephone:

Email:

Fax:

Profession:

analytical psychologist

candidate in analytical psychology / psychoanalysis (please specify)

medical doctor / psychiatrist

psychoanalyst

mental health practitioner

social worker

other (please specify)

Dates of arrival and departure:

single (no accommodation)

single (with accommodation)

writing workshop fee £90 / US $135

double (one participant)

double (two participants)

Total Fee Enclosed:

Cancellations will be accepted up to 15 February 2013 with a refund less
an £80 / US $120 administrative fee.
No refund will be made after that date.

For further information contact:
Pramila Bennett at journal.jap@btconnect.com

Once completed please email to journal. journal.jap@btconnect.com or return to
Journal of Analytical Psychology, 1 Daleham Gardens, London NW3 5BY