CENTRAL COAST PSYCHOLOGICAL ASSOCIATION

An Affiliate of the California Psychological Association

Membership Application and Renewal Form - 2005

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A.  Member Information

Name:             _________________________________  __________________________  _____

(Last)                                                                               (First)                                                                (MI)

Preferred              ________________________________________________________________________

Mailing            (Street of Post Office Box Number)  Is this your mailing address?  Yes, ____, No ____

Address:         _______________________________________________  _________  ______________

(City)                                                                                                                           (State)              (Zip Code)

Phone/Fax:       __________________________________     ___________________________________

(Preferred telephone number, office or home)                 (Preferred fax number, office or home)     

Email:                         ________________________________________________________________________       

Education:        _____________    _____________________________________________  ________           

(Highest Degree)            (Highest Degree Granting Institution)                                                                            (Mo/Yr)                    

CA License:     _____________ State of Issue _______________ Expiration Date __________________

Memberships:            CPA:  Yes ____, No ____; Year Joined ____; APA:  Yes ____, No ____; Year Joined _____

                        Please check if you would like information on how to join CPA _______ or APA ________

Agreement:                I agree that the above information may be published in the CCPA Membership Directory or on the CCPA Web Site. Please initial here if you agree _____________.  Thank you.

B.  Ethics Waver

Has your psychological practice been restricted, suspended, or in any fashion limited by any hospital, medical staff, licensing body, or have you had a formal accusation made by the Board of Psychology or any regulatory body, or have you been convicted of any felony?  Yes ____, No ____.  Also, I have read and agree to abide by the Code of Ethics of the California Psychological Association.  Note that the Code of Ethics for CPA and other state psychological associations is published on the APA Web Site, located at APA.ORG.

Signature:  ____________________________________________________________________ Date:  ___________________

                    Please sign name as it appears on your license.

C.  Professional Interests and Responsibilities

Consider becoming involved in your local psychological association.  Please check one or more areas of interest and you will contacted by a member of CCPA:  Ethics _____, Information and Referral _____, Newsletter _____, Disaster Response _____, Continuing Education _____, Membership _____, Publicity _____, Government Affairs _____, Hospital Practice _____, Web Site _____, Public Interest _____, Social _____, Other Interests __________________________________________________________________

D.  Payment Information*

Check one:  Member ($60) ______; Associate Member ($45) ______; Student Member ($30) ______

Please make your check payable to CCPA and forward the check, along with this application, to Dr. Bill Safarjan, CCPA Membership Chair, 5100 Cascabel Road, Atascadero, CA 93422-2345.  Thank you.

*  Note that:  Full Members must hold a doctorate degree in psychology and may vote and hold office in the Association.  Associate Members must hold a masters-level degree in a mental health related field and may not vote or hold office.  Student members may neither vote nor hold office and must be enrolled in a graduate program in a mental health related field.