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_______________________________________