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Island Psychological Association Membership Application Category of Membership: (See Membership Information brochure, or www.ripsych.org/join.html) Clinician
____ $100.00 ($100, 1st year; $175, 2nd year; $250, 3rd year) Associate ______ $85.00 Student Affiliate ______ $35.00 Living and working out of state ____ $100 Academician/Researcher ____ $100 Name: ___________________________________________________ Degree: _______________________ Home Address: __________________________________________________________________________ Office Address: __________________________________________________________________________ Preferred mailing address: Home ____ Office ____ Home Telephone: ____________________ Office Telephone: _______________________ Fax: _______________________ Email: ________________________________________ Date of Birth: ___________________________ Current Position:________________________________________________________________ Are you
a licensed practicing clinician in Rhode Island? Yes ___ No ___ MEMBERSHIP STATUS IN THE AMERICAN PSYCHOLOGICAL ASSOCIATION: Member ______ Fellow ______ Associate _______ Student ______ None ______
ACADEMIC BACKGROUND: List institution, location, degree and date awarded, and area of concentration 1. _______________________________________________________________________________________ ________________________________________________________________________________ 2. _______________________________________________________________________________________ ________________________________________________________________________________ 3. _______________________________________________________________________________________ ________________________________________________________________________________ PROFESSIONAL EXPERIENCE (For Associate applicants): Please list institution and address; dates from month/year to month/year; position; immediate supervisor and supervisor’s title; and number of hours weekly. 1. _______________________________________________________________________________________ ________________________________________________________________________________ 2. _______________________________________________________________________________________ ________________________________________________________________________________ 3. _______________________________________________________________________________________ ________________________________________________________________________________ ENDORSEMENTS: If you are applying for Member or Associate status, AND you are NOT ALREADY a member of the American Psychological Association, endorsement by two Rhode Island Psychological Association Members is required. If you are applying for Student Affiliate status, endorsement by two RIPA members is required. "I hereby endorse the above-named applicant as a person of acceptable professional integrity and ethical practice." Name __________________________________ Signature_______________________________ Name __________________________________ Signature_______________________________ ATTESTATION: In making this application for RIPA membership, I subscribe to and will support the objectives of the Association "to advance Psychology as a science, a profession, and as a means of promoting human well-being." In making this application for membership in RIPA, Inc., I certify that my professional activities are and have been consistent with the APA’s Ethical Principles of Psychologists. I also certify that the information contained on this application is correct to the best of my knowledge. Signature ___________________________________________ Date ______________________ Please enclose a check for appropriate dues made out to "Rhode Island Psychological Association." Return to: Rhode Island Psychological Association 1643 Warwick Ave., PMB 103 Warwick, RI 02889 |