Member/Associate Member Application

State/Province/Country

Position or Title

Department

Employer, Institution or Firm

Employment Setting Code
Select Employment Setting Code 01 Psychology department 02 Education department 03 Business school or department 04 Other academic department or unit 05 Management or administrative office 06 Student counseling or services 07 Research Center or Institute 08 Other university setting 11 Psychology department 12 Education department 13 Business school or department 14 Other academic department or unit 15 Management or administrative office 16 Student counseling or services center 17 Research center or Institute 19 Other four-year college setting 21 Two-year college 22 Medical school, psychiatry department 23 Medical school, other than psychiatry department 24 Professional school of psychology, affiliated with a university 28 Professional school of psychology, free-standing 29 Professional school (not listed above e.g. law, nursing) 25 Elementary or secondary school 28 School system district office 27 Other educational setting (e.g. vocational or special education) 31 Public general hospital 32 Private general hospital 33 City/county/state psychiatric hospital 34 Not for profit, private psychiatric hospital 36 For profit, private psychiatric hospital 35 VA hospital 37 Military hospital 41 Individual private practice 42 Group psychological practice 43 Medical psychological group practice 44 Outpatient mental health clinic, free-standing 45 Community mental health center or clinic (CMHC) 38 Independent Practice Association (IPA) 46 Health Maintenance Organization (HMO) excluding IPAs 39 Preferred Provider Organization (PPO) 70 Other managed care-setting 47 Counseling or guidance center (not university or college) 40 Nursing home 48 Specialized health service (e.g. substance abuse or mental retardation) 49 Other human service setting 51 Self-employed, not private practice (e.g. consulting) 52 Consulting firm 53 Private research organization or lab 54 Government research organization or lab 55 Business or industry (excluding consulting firm or research organization) 61 Criminal Justice system 62 Military service (not military hospital) 63 Federal government agency (other than above settings) 64 State government agency (other than above settings) 65 Local government agency (other than above settings) 66 Other non-profit organization 69 Other non-educational or non-service setting not listed above 75 Not currently employed

Employed From (Month/Year)

Are you licensed as a psychologist by a state or provincial psychology board?
Yes No

If no, are you planning to pursue a license to practice as a psychologist?
Yes No

Have you at any time been convicted of a felony, sanctioned by any professional ethics body, licensing board, or other regulatory body or by any professional or scientific organization?
Yes No

If yes, please provide explanation below:

Applicant's Signature

Date