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(914) 723-3030

 

 

WCPA's Membership Application

 

APPLICATION FOR MEMBERSHIP

1. Dr.  Mrs.  Ms. Mr.
First Name: Last Name:

2. Telephone:   (o)    (h)     (cell)

3. Email address:

4. Home Address: Zip:

5. Business Address: Zip:

[Note: CHECK ADDRESS TO WHICH WCPA MAIL SHOULD BE SENT]

6. Present Position:

7. Describe Duties:


8. Academic Training:
From:                 To:                          Institution                               Degree & Date      Major


9. Are you licensed in New York State under Article 153 of the NY State Education Law? Yes No

10. Are you certified in New York State as a School Psychologist under Article 143 of the NY State Education Law?
Yes No  

11. Are you engaged in private practice? Yes No
NOTE: Only those licensed under Article 153 of the NY State Education Law may engage in independent practice as psychologists.

12. Specify membership status in other Professional Societies/Associations: (i.e. full member, student, etc.)



I have read, and I subscribe to, the codes of ethics of the American Psychological Association and the New York State Psychological Association.

Date: Signature of Applicant