Alameda County Psychological Association


New Member Application

New memberships received after June 31 of any year renew December 31 of the following year.

Last Name First Name Middle Initial(s) Userid
Mailing Address City State  Zip  
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Fax Phone Number  
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Email Address  
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Validate Email Address  
 
Are you a member of CPA? Yes No         Are you a member of APA? Yes No
Membership in the California Psychological Association (CPA) and the American Psychological Association (APA) is recommended, but not required, for membership in ACPA.
 
Highest Degree Earned Area of Concentration Month Year
Other:
Institution City State
 
License Number Type Date Licensed
Month           Year		 State Years of Clinical Experience
    
List other licences indicating type, state, and date issued:
 
Please indicate the type of membership for which you are applying:
Full Members:

(1) work as a psychologist or reside within Alameda County, (2) hold a doctorate or equivalent degree in psychology, or (3) a license as a psychologist in the State of California, or (4) a Diplomate of the American Board of Professional Psychology.

   $120.00  
  3rd Year of Licensure $90.00  
  2nd Year of Licensure $75.00  
  1st Year of Licensure $60.00  
  Enhanced Directory Listing   What is this? $50.00  
Associates: Hold a masters degree in psychology or equivalent and work or reside within Alameda County $100.00  
Affiliates: Those interested in psychology who do not meet the criteria for any other membership category $50.00  
Graduate Student Members: Are enrolled in a graduate psychology program or engaged in a postdoctoral psychology training program in Alameda County $25.00  
Out-of-county Members: Psychologists, Associates, or Affiliates who live and work out of county and wish to participate in ACPA $50.00  
Which county associations do you belong to?
Voluntary PAC Contribution: The CPA-PAC supports legislative activities to protect and promote the practice of psychology in California. This contribution is a non-deductible expense $50.00  
TOTAL DUES: $
  (Please make check payable to ACPA, or pay on-line with PayPal)
NOTE: ACPA Membership expires on the first of each year, and must be renewed annually.
   
PLEASE READ THE FOLLOWING DECLARATION OF PROFESSIONAL ETHICS, AND THEN INDICATE YOUR CONFORMITY BY CHECKING THE BOX BELOW:
I have never had action taken against me for unprofessional conduct by a licensing agency or professional organization. True False
I have never been convicted in a court of law of a criminal charge. True False
I am not currently being investigated by any of the above. True False
The information that I have provided is true and verifiable. Yes No
I adhere to the APA Code of Ethics. Yes No
 
If you have answered false or no to any of the above, please send a detailed letter of explanation to:
ACPA, 4200 Park Blvd., #200, Oakland, CA 94602
 
By checking this box, I certify that the information provided in this application is true and verifiable, and that I have read and answered truthfully the Declaration of Professional Ethics above.
 
The information on this application will be made available to the public on the ACPA website membership list, for all members,and the Online Directory of Psychologists for full, licensed members, unless otherwise indicated by the member.  Please check the appropriate boxes to suppress information you do not want on the ACPA website.