Psychological Association of the PhilippinesRoom 208, Second Floor, PSSC Diliman, Quezon City Tel./Fax: 453-8257 E-mail add:
[email protected] MEMBERSHIP APPLICATION FORM ( ) New Approved Category: _________________________ PERSONAL INFORMATION Home Name:Address: Email Address: Surname First Name Mobile Number: Middle Name Nickname Sex: Landline Number: Please If Certified Specialist, please check all If Licensed, please indicate type: that applies: ( ) Male ( ( ) Psychologist (RP) Membership in Divisions &/or ( ) Female Date Issued: ____________ Specialty Interest Group, please choose ( ) Assessment ID Number: _____________ only 3 and rank accordingly: ( ) Clinical Resolution No: __________ ____ Assessment ___MHPSS ( ) Counseling ( ) Psychometrician (RPm) ____Developmental ___LGBT ( ) Developmental Date of Birth: Date Issued: ____________ ____Clinical ____Teaching ( ) Educational ID Number: ____________ ____Counseling ( ) Industrial-Organizational Resolution No: __________ ____Educational ( ) Social m d y ____IO m d y ____Social If NOT Certified Specialist, please indicate area of specialization: ___________________________ EDUCATIONAL BACKGROUND Units Year Degree Major Specialization School/Institution Completed* Graduated *State the number of units completed in a degree program if currently working for a degree PROFESSIONAL EXPERIENCE Year Position/Title Institution Contact Number Nature of Work Employed Please check which PAP activities you wish to be invited to or participate in: Conference Management (registration, program, etc) Outreach (disaster response, psychological first aid, etc) Finance committee (sponsorships, fundraising, etc) Certification (accreditation of CPE providers & programs, etc) Research (capability building workshops, etc) Awards (evaluation of criteria, judging, etc) Teaching (capability building workshops, etc) Public awareness/advocacy (writing columns, giving media I interviews, etc) Please attach a) Transcript of Records (TOR) for Non RP/RPm applicants b) Licensure ID for RP and RPm (for those with licensure) In making this application, I subscribe to and will support the objectives of the Psychological Association of the Philippines as set forth in its Constitution and By-laws and the Ethical Principles of Psychologists and the Code of Conduct as adopted by the Association, and I affirm that the statements made in this application correctly represent my qualifications and understand that if they do not, my affiliation may be voided. Date Signature PAP shall be posting the names and contact email of its members who are licensed and certified. Should you wish NOT to have any contact information released or made public at any time, please check here ( ).