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MPAGS Status Change Form



Name:


I am currently an MPAGS member and now and qualify for membership as a:
Full Member Criteria for member status: (a) Maintain ethical standards of professional conduct as set forth by the American Psychological Association in its Code of Ethics and as set forth in Maryland Code of Regulations; (b) Possess a doctoral degree that is psychological in nature from an institution of higher education fully accredited by a regional accrediting body recognized by the Council on Post-secondary Accreditation or an institution that is publicly recognized as a member in good standing with the Association of Universities and Colleges of Canada, or licensure as a Psychologist in the State of Maryland.
Non-resident Affiliate Criteria for Out-of-State Affiliate status: Non-resident (out-of-state) affiliates do not live in Maryland or provide psychological services in Maryland. However, Non-resident Affiliates who otherwise meet all requirements for Full Member, or Associate status may apply for Full Member of Associate status, with all rights and privileges. Such members will be required to pay the same dues, at appropriate levels, as other Full Members or Associates, respectively. Affiliates shall not have voting rights or be eligible for elective office. Affiliates may serve as non-voting members of subcommittees but may not serve as chair.


Dues:

Addresses
Home

Street: 

City:     State:    Zip: 

County:  

Phone:  

Fax:  


Primary Employment

Title: 

Employer: 

Address: 

City:     State:    Zip: 

County:  

Phone:  

Fax:  

Website:  


Secondary Employment

Title: 

Employer: 

Address: 

City:     State:    Zip: 

County:  

Phone:  

Fax:  

Website:  


Communication

Preferred Mailing Address:
 


My e-mail address for MPA business (newsletters, listservs and/or workshop confirmations) is:


Confirm email address:

I would like to receive the quarterly newsmagazine, The Maryland Psychologist, by OR


Personal Information

Graduate College/University:   Graduation Date:

Department: Degree:



APA member

National Register

ABPP     Specialty ABPP Area



Psychology Field/Occupation









Employment Setting










Military









If you are licensed in Maryland or a member of APA, you need to provide no further credentials. Applicants who are not Members or Associate Members of the American Psychological Association must have an official copy of their graduate transcript(s) sent to the MPA Membership Board.


All applicants must answer the following questions:

1. Have you ever been expelled, suspended, or asked to resign from any national, state, or local psychological association? Or, have you ever resigned or agreed to any other action while an investigation was pending by such an association?    

If yes, please provide details, including whether you have been reinstated or are eligible for reinstatement.


2. Has any governmental body responsible for regulating or licensing the practice of psychology ever placed you on suspension, probation, or otherwise restricted or revoked your authority to call yourself a psychologist or practice psychology? Or, have you ever taken steps to limit or halt your practice of psychology or agreed to any other action while an investigation was pending by such a body?    

If yes, please provide details, including whether you have been reinstated in full or are eligible for reinstatement.


By my signature, or by submitting this application electronically, I hereby attest that the information provided above and any attached information is true, complete, and accurate. I have read and agree to adhere to the ethical standards of professional conduct as set forth in the American Psychological Association's code of ethics.


Signature  



Payment

Membership fee (2018-2019 membership year, through 8/31/2019)






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Expiration Date:

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Billing City:

Billing State:

Billing Zip:



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Once you submit your payment, you will receive an e-mail confirming that MPA has received your application. Applications are approved at monthly Board of Directors' meetings September to June of each year. Once your application has been approved, you will be sent a new member packet that includes your username and password to access exclusive member-only resources on the MPA website, begin receiving newsletters and updates from MPA, and have access to numerous other benefits.