|
|
|
|
You are welcome to apply for membership in NSPA. Qualifications for membership are listed at the bottom of the application. (Please print out and mail to the address below.) Membership Application Napa-Solano Psychological Association A Chapter of the California Psychological Association P.O. Box 3743, Napa, CA 94558 I am applying for: NAME:__________________________________________________ DEGREE_________________ OFFICE ADDRESS:____________________________________________________________________ MAILING ADDRESS (if different)________________________________________________________ Work Phone#: ____________________________ Home Phone #: _____________________________ Cell Phone #: ___________________ FAX #::_____________________ E-mail___________________ EMPLOYER: Self (Private Practice) Other:: _____________________________________ GRADUATE SCHOOL(S):________________________________________________ YEAR_________ LICENSED? NO YES Type _________License #____________ State_____ Year issued_______ OTHER LICENSES:___________________________________________________________________ AREA(S) OF SPECIALTY:_______________________________________________________________ _____________________________________________________________________________________ PROFESSIONAL MEMBERSHIPS: APA CPA OTHER:____________________________________ Other things you would like NSPA to know about you:________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ (Please attach additional sheets if you run out of space.) Annual dues are $55.00 for Full Members, $45 for Associate Members. Please make checks payable to NSPA. Mail application and dues to the address above or give them to a member of the NSPA Executive Committee. (Although optional, a Curriculum Vitae would also be appreciated.) Signature_______________________________________ Date___________________________ * Full Members shall have: (1) a Doctorate in Psychology from a regionally accredited institution, or (2) a license as a psychologist in the State of California, or (3) a Diplomate of the American Board of Professional Psychology, or (4) eligibility for Member status in APA or CPA.** Associate members shall have: (1) a Masters Degree in Psychology (or an equivalent degree in the behavioral sciences) from a regionally accredited institution, or (2) eligibility for Associate status in APA.
|
|
|
