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Membership Application Form



Name:


I have read the Rules of Membership 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.


Addresses
Home

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Fax:  


Primary Employment

Title: 

Employer: 

Address: 

City:     State:    Zip: 

County:  

Phone:  

Fax:  

Website:  


Secondary Employment

Title: 

Employer: 

Address: 

City:     State:    Zip: 

County:  

Phone:  

Fax:  

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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 enroll in the ECPN Listserv: an interactive e-mail communication list for early career members with doctorate 7 years or less to discuss career issues and concerns.


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 (PhD, PsyD, MS, etc.):


Licensed in MD Date:   Licensed in DC   VA


APA member Yes   No

National Register Yes No

ABPP Yes No     Specialty ABPP Area


Psychology Field/Occupation

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


Specific Areas of Interest

1.

2.

3.

4.

5.

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 licensed in Maryland or a member of APA, you need to provide no further credentials. Applicants who are neither licensed in Maryland nor members of the American Psychological Association must have an official copy of their graduate transcript(s) sent to the MPA Membership Board.

I am licensed in Maryland

I am an APA member.

I am having my transcripts sent.


How did you hear about MPA? If a colleague or friend, please include their name:


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   Today's date



Payment

Membership fee (2017-2018 membership year, through 8/31/2018)


Applications submitted after 5/22/17 will be valid for membership through 8/31/18. 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.

Licensed psychologists during or prior to 2014 - $350
First year of licensure (licensed in 2017) - $120
Second year of licensure (licensed in 2016) - $195
Third year of licensure (licensed in 2015) - 250
Fourth year of licensure (licensed in 2014) - $300
Doctoral degree, non-licensed - $235
Nonresident Affiliate - $235


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:



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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.