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Associate/Affiliate Membership Application Form



Name:



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:
    Home  
    Primary Employment
    Secondary Employment


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


Confirm email address:

I authorize MPA to send e-mails to me as necessary.

I would like to enroll in the MPA Member Listserv: an interactive e-mail communication list used by members to discuss pertinent information with colleagues, i.e., referral sources, ethical questions, practice information etc.

I would like to enroll in the MPANEWS: an e-mail announcement list to keep you informed of important issues related to MPA.

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


Personal Information

Graduate College/University:   Graduation Date:

Department: Degree:


I am currently licensed as a:
Not Applicable
LCPC
Social Worker
Other:


I am currently supervised (if applicable) by: at my place of employment listed above.


Psychology Field/Occupation

Academic/ Teaching
Administration
Clinical
Counseling
Industrial/ Organizational
Neuropsych
Research
School Psychology


Employment Setting

Academic Institution
Business
College/University
Counseling Center
Community Mental Health Clinic
Criminal Justice System
Government Agency
Medical Institution


Military
Non-profit Human
Services
Private Practice (Group)
Private Practice (Solo)
Psychiatric Institution
Research Institution
School System
VA Hospital



If you are a Members or Associate Members, 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.

I am an APA Member or Associate Member.

I am having my transcripts sent, or will send them to members@marylandpsychology.org.


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? No Yes

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? No Yes

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 (Membership expires 8/31/2018)


2017-18 Associate/Affiliate Dues: $235 $117.50


Applications submitted after 6/10/16 will be valid for membership through 8/31/17. Your application will not be approved by the Board of Directors until their September meeting, but you will be eligible for some member benefits as soon as we have received your application.

 


When entering your Credit Card information please include the billing address that matches your credit card billing address. Thank you!

Name On Card:

Credit Card Type:

Credit Card Number:

Expiration Date:

Billing Street Address:

Billing City:

Billing State:

Billing Zip:



(Your credit card information is being sent over a secure server.)



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.