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 ICP DIRECTORY UPDATE FORM

 

In order to be included in the  ICP Directory, your current dues must be paid in full, and this form completed, returned, and received by March 1,:

        By mail Or by entering information in the body of an e-mail (no scanned attachments) to: 

Secretary General:  Dr. Matti K. Gershenfeld

8302 York Road, B-45; Elkin Park, PA 19027 USA

Email:  mattikg@comcast.net

 

Please be assured that the completed Directory will not be produced or disseminated electronically, via web site or e-mail, in order to protect the privacy and safety of ICP members and their contact information.

 

This form must be completed and returned in order to be listed in the Directory. Only information you include on the form will be printed

Please carefully  type or print your information on all lines that apply to you.

Last Name:__________________________________________________Title (Dr., Prof., Mr., Ms., Mrs., Other)_______________

First Name:___________________________________________Middle Name or Initial:__________________________________

Address:____________________________________________________________________________________________________

Address(cont’d):____________________________________________________________City:______________________________

State/Province:_________________________Zip Code:______________________Country:_______________________________

Telephone(s):________________________________________________________________________________________________

Fax:_______________________________________E-Mail:__________________________________________________________

Highest Degree Earned________________________________Year Earned_____________________________________________

       College/University__________________________________City_______________________Major______________________

Primary Current Position______________________________________________________________________________________

Secondary Current Position____________________________________________________________________________________

Primary Field of Psychological Interest (choose number from list below)_______________________________________________

Second and Third Field of Psychological Interest (choose two numbers from list below)__________________________________

01. General Psychology                                 16. Environmental Psychology           30. Population

02. Psychology of the Arts                              17. Evaluation & Measurement           31. Psycholinguistics

03. Assessment of Programs                        18. Experimental Psychology             32. Psychology of Women

04. Behavior Modification                                19. Forensic Psychology                    33. Psychopharmacology

05. Child, Youth, & Family Services               20. Gerontology (Adult                        34. Psychotherapy

06. Clinical Psychology                                          Development & Aging)                35. Rehabilitation Psychology

07. Community Psychology                           21. Health Psychology                        36. Religious Issues in Psychology

         & Mental Health                                      22. History of Psychology                   37. School Psychology

08. Comparative Psychology                         23. Humanistic Psychology                38. Social Issues

09. Consulting Psychology                             24. Industrial & Organizational            39. Social Psychology

10. Counseling                                                        Psychology                                 40. Statistics, Computer Science

11. Cross-cultural Psychology                       25. Mental Retardation                        41. Teaching of Psychology

12. Delinquency                                              26. Neuropsychology                          42. Vocational, Occupational Psychology

13. Developmental Psychology                      27. Physiological Psychology             43. Other Psychological Field____________________

14. Educational Psychology                           28. Personality                                          _________________________________________

15. Engineering Psychology                           29. Political Psychology                      44. Other Professional Field______________________

                                                                                                                                          _________________________________________

Languages in which Fluent(including English)____________________________________________________________________

 

Member Status(es) (please fill in year for all that apply--these dates will be checked against the ICP Secretariat files):

Class of Membership         Year Joined     

Member                                ___________                Professional and Life Memberships ended in 1999. Previous memberships honored:

Associate                             ___________                       Permanent Member       ________

Professional Affiliate            ___________                     Life Member                   ________

Student Affiliate                    ___________

 

I agree to have the information presented above printed in the 2004 ICP Directory.                                                                                                                                                                                      SIGNATURE_______________________________________