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International Council of Psychologists

 Matti K. Gershenfeld, Ed.D., Acting  Secretary-General

The Colonade, #1201 100 Old York Road  Jenkintown, PA 19046

Tel. 215-884-4664  Fax: 215-884-4665  Email: matti@nni.com

 

Web Site: http://icpsych.tripod.com 

 
ICP Application Form
(for New Members)

Please read instructions regarding Classification of Membership and Membership Dues.

_____Member _____Associate _____Professional Affiliate _____Student Member

NAME: ____________________________________________________________________________________
Last name (family name) Mr/Mrs/Ms/Prof/Dr First Name (given name) Middle Initial

MAILING ADDRESS: _________________________________________________________________________

____________________________________________________________________________________________

Office Phone: _________________________________ Home Phone: ________________________________

Fax: __________________________________________ E-mail address: ______________________________

PROFESSIONAL ADDRESS (if different from Mailing Address): Position. institution (or private practice), address

_____________________________________________________________________________________________

_____________________________________________________________________________________________

DEGREES OR CERTIFICATES (Highest appropriate): Degree, date, major subject, institution, location.

_____________________________________________________________________________________________

 

Student Member only: Institution _____________________________________________________________


Major Profession ______________________________ Anticipated degree __________________ Date __________

EXPERIENCE: Dates, title, institution, location. Your last 2 positions. or last ten years.

___________________________________________________________________________________________________

___________________________________________________________________________________________________ 

MEMBERSHIPS IN PROFESSIONAL SOCIETIES: Society name, date of admission, class of membership.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

TWO ENDORSERS: Names, addresses, and signatures (see instructions).

___________________________________________________________________________________________________

___________________________________________________________________________________________________

If your interest in ICP was stimulated by someone other than an endorser, please give name:

___________________________________________________________________________________________________

LANGUAGES: ______________________________________________________________________________________

Signature ______________________________________________________ Date ______________________________

 Membership year is Jan I - Dec 31. If application is received after August 15, dues will be credited to the following year.

ENCLOSE DUES, AND MAIL TO: 

Financial Officer: Dr. Paula Leder
c/o Dr. Matti Gershenfeld The Colonade, Ste. 1201, 100 Old York Rd., Jenkintown, PA 19046 USA

Telephone: ++213-884-4664
FAX: ++215-884-4665
Email: pleder@nni.com