APAGS Advocacy Coordinating Team Self-Nomination Form

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APAGS Advocacy Coordinating Team Self-Nomination Form

This form can be used by any APAGS or APA member who wishes to nominate him or her self to be an ACT Campus Representative and member of the APAGS Advocacy Coordinating Team. Nominees for membership in APAGS-ACT must be Student Affiliates of APA and members of APAGS whose membership is in good standing. There is only one APAGS-ACT Campus Representative allowed per Psychology Department program. You can go here to see if your school or department currently has an APAGS-ACT Campus Representative.

If you are already a member of APAGS-ACT, and you wish to notify APAGS that your contact information has changed, you can do so here.

--- Required fields are in bold red letters, and are marked with an * ---

* Your APA member number: -

Note: If you are unsure of your Member Number, you can verify it with the Membership Office at (800) 374-2721

Your name:
* First:
Middle Initial:
* Last:

Your address:
* Street 1:
Street 2:
* City:
* State:
* Zip Code:
Four-digit zip extension
Your phone numbers:
Work or School:	() -
* Home:	() -

* Your e-mail address:
Note: Please double-check to make certain your e-mail address has been entered correctly!
* The school you (or your nominee) will represent:
*The type of psychology program you (or your nominee) will represent:
	(e.g., I/O Psychology)

If you are nominating someone other than yourself to be a Member of ACT, please provide the following information:

Nominee's first and last name:
Nominee's e-mail address:
Nominee's phone number:

* Please include a written statement in the text box below regarding your (or your nominee's) qualifications for Membership in ACT:

If you are nominating someone other than yourself to be a Member of ACT, please use this space to provide a ~350 word statement describing why your nominee would be an effective grassroots organizer and advocate for psychological issues.
If you are nominating yourself to be a Member of ACT, please use this space to provide a ~350 word statement describing why you are interested in legislative advocacy, what issues in particular are important to you, and why you feel you'd be an effective advocate for psychology.

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