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Middle Initial(s) |
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| Mailing Address |
City |
State Zip |
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Suppress display of address |
| Fax |
Phone Number |
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Suppress display of phone number |
| Email Address |
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Suppress display of email |
| Validate Email Address |
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| 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. |
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| Highest Degree Earned |
Area of Concentration |
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Other:
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State |
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| License Number |
Type |
Year Licensed |
State |
Years of Clinical Experience |
| PSY
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| List other licences indicating type, state, and date issued:
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| Please indicate the type of membership for which you are applying: |
| Full Members: |
Reside in Alameda County and 1) work as a psychologist and hold a doctorate or equivalent in psychology, or 2) hold a license as a psychologist in California, or 3) be a Diplomate of the American Board of Professional Psychology |
$
.00 |
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| Associates: |
Hold a masters degree in psychology or equivalent and work or reside within Alameda County |
$
.00 |
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| Affiliates: |
Those interested in psychology who do not meet the criteria for any other membership category |
$
.00 |
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| Graduate Student Members: |
Are enrolled in a graduate psychology program or engaged in a postdoctoral psychology training program in Alameda County |
$
.00 |
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| Out-of-county Members: |
Psychologists, Associates, or Affiliates who live and work out of county and wish to participate in ACPA |
$
.00 |
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| Which county associations do you belong to?
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| 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 |
$
.00 |
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TOTAL DUES: $
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(Please make check payable to ACPA) |
| NOTE: ACPA Membership expires on the first of each year, and must be renewed annually. |
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| 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 |
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If you have answered false or no to any of the above, please send a detailed letter of explanation to:
ACPA,
1164 Solano Avenue,
Box 407,
Albany, CA 94706 |
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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. |
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| The information on this application will be made available to the public on the ACPA website full membership list and the Online Referral Service only 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. Psychology graduate student members will be listed on the website membership list under that heading. |
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