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DC Psychological Association
  

 
 
 

Membership Application


Please see Instructions for membership requirements and terms.

Contact Information
(*Required field)
Name:*
Prefix First* Middle Last* Suffix
Country:*
Address:*
 
 
City:*
State/Province:*
Zip/Postal Code:*
Email:*
Please reenter Email for verification:*
Date of Birth:* (mm/dd/yyyy)
Gender:* Male Female
 We require either a work phone number or a home phone number to facilitate follow-up *
 Work Phone:   Ext:       Home Phone:   Ext:       Fax:
Highest Degree in Psychology or Related Field
Highest degree:*
If "other" highest degree, please specify:
Major field of the highest degree:*     Instructions
If "other" major field, please specify:
Degree Month:* (e.g. 03)          Year:* (e.g. 2002)
Institution:*
Department:*
Country:*
City:*
State/Province:*
Current Major Field and Current Employment
Current major field:*
If "other" major field, please specify:
Employment setting:*     
(Select general and details)     		 General setting
Setting details
If "other" employment setting, please specify:
Country where you are employed*:
Position or title:
Department:
Employer, Institution or Firm:*   (Required only in U.S. and Canada)
Employer Zip:*   (Required only in U.S. and Canada)
Employed from Month:* (e.g. 03)         Year:* (e.g. 2002)

Licensure/Ethics
Are you licensed as a psychologist by a state or provincial psychology board?:* Yes No
Country where you are licensed:* Instructions
State/Province where you are licensed:*
If no, are you planning to pursue a license to practice as a psychologist?: Yes No
Have you at any time been convicted of a felony, sanctioned by any professional ethics body, licensing board, or other regulatory body or by any professional or scientific organization?:* Yes No
If yes, please explain:
(Only first 350 characters will be submitted)

Other Information
Is this your first application for membership in DCPA?:* Yes No
Former Name (if any):
Affiliate number or former member number(if any): (8 digits, no dash)
What is your ethnicity? (Mark all that apply):
American Indian/Alaskan Native   Asian, or Pacific Islander Caucasian/White  
African American/Black Hispanic/Latino   Other
Your affiliation with DCPA is considered part of the public record. If you DO NOT wish to have any contact information released or made public, please check here:

In making this application, I subscribe to and will support the objectives of the District of Colombia Psychological Association as set forth in DCPA Bylaws, and the Ethical Principles of Psychologists and the Code of Conduct, and I affirm that the statements made in this application correctly represent my qualifications for election, and understand that if they do not, my affiliation may be voided. The Bylaws can be reviewed at DCPA's Web site link.

Indicate your agreement:* Yes No