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                 INTERNATIONAL COUNCIL OF PSYCHOLOGISTS       Page 1 of 2

Dr. Matti K. Gershenfeld, Secretary General

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

Email:  mattikg@comcast.net

ICP WEB SITE: http://icpsych.tripod.com

 

2005 MEMBERSHIP DUES STATEMENT

ICP Membership Fees and this Dues Form are due JANUARY 1, 2005

($10 Late Fee applies after January 31, 2005)

 

DUES INFORMATION

 Country or Country Area determines Dues Category.  Check one.  All fees are in US Dollars.

 

______ $85 US DOLLARS-----CATEGORY “A” COUNTRIES OR AREAS

               (Australia, Austria, Bahrain, Belgium, Brunei, Canada, Denmark, Finland, France, Germany, Great Britain, Greece, Hong Kong,

                Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Qatar, Saudi Arabia,

                Singapore, Spain, Sweden, Switzerland, Taiwan, United Arab Emirates, USA)

______ $43 US DOLLARS-----CATEGORY “B” COUNTRIES

               (Antigua & Barbuda, Argentina, Bahamas, Barbados, Brazil, China, Croatia, Cyprus, Czech Republic, Iran, Korea, Malaysia, Malta,

                Mexico, Oman, Poland, Seychelles, Slovakia, Slovenia, South Africa, Suriname, Turkey, Venezuela, Yemen)

______ $23 US DOLLARS-----CATEGORY “C” COUNTRIES

               (All countries other than those included in A or B categories)

______ STUDENT AFFILIATE:

               _____$23 US DOLLARS for Category A countries or areas

               _____$20 US DOLLARS for Category B countries

               _____$15 US DOLLARS for Category C countries

               (Each year, all students must send, with this form, the name, address, and phone number of the college or university, and of the Major

                professor, and expected date  of graduation.)

 

______ LIFE MEMBERS:

              (Required 50% of Country or Area Category Dues per 1999 Salem and 2004 Jinan Board Decisions.)

______ PERMANENT MEMBERS:

              (Suggested Voluntary Contribution 50% of Country Category Dues will help defray ICP costs to service your membership.)

 

1._____2005 ANNUAL DUES…………………………………………………………………………Amount $____________

2._____LIFE MEMBER 50% DUES………………………………………………………………….. Amount $____________

3._____PERMANENT MEMBER CONTRIBUTION ……………………………………………….. Amount $____________

4._____STUDENT AFFILIATE………………………………………………………………………. Amount $____________

5._____“MATTI MATTERS” GROWTH FUND…………………………………………………….. Amount $____________

               (Honor former Secretary-General Matti Gershenfeld; to fulfill ICP objectives and future plans)

6._____DISCRETIONARY SPONSOR FUND………………………………………………………. Amount $____________

               (Help members in extreme economic need or Sponsor a Category C member)

7._____SUKEMUNE / BAIN EARLY CAREER RESEARCH FUND……………………………… Amount $____________

8._____DENMARTK / GUNVALD GENDER RESEARCH FUND…………………………………Amount $____________

9._____STUDENT SPONSOR FUND………………………………………………………………... Amount $____________

               (Help students in financial need in A, B, or C countries)

10.____Late Fee (Payment after January 31 --  I include $10 late fee)……………………….. Amount $____________

11.____DUES for 2004 which I forgot to pay (Late fee penalty waived)…………………….. Amount $____________

              TOTAL (US Dollars only)…………………………………………………………….. Amount $____________

 (NOTE:  A Member Dues Form must accompany payment for each

Sponsored/Gift Recipient.  Include name(s) with address, staste, zip or

mail code, country, telephone and/or fax number, and e-mail address.)                                                      COMPLETE PAGE 2 ALSO.

  

                 INTERNATIONAL COUNCIL OF PSYCHOLOGISTS       Page 2 of 2

 MEMBER INFORMATION

 

PLEASE TYPE OR PRINT CLEARLY

 

PREFERRED TITLE:     _____ Dr         _____Prof         _____ Mr         _____ Mrs          _____ Ms

 FULL NAME___________________________________________________________________________________________

PREFERRED MAILING ADDRESS________________________________________________________________________

CITY_____________________________________________________

STATE______________________________________

ZIP/MAIL CODE___________________________________COUNTRY___________________________________________

TELE-HOME_____________________________TELE-WORK___________________________________________

FAX____________________________________E-MAIL________________________________________________

 PAYMENT INFORMATION

 ICP accepts payment only on US Dollar checks from USA banks OR US Dollar Postal Orders OR Visa or MasterCard.

ICP does not accept wire transfers or foreign checks or foreign postal orders—all will be returned at member’s expense.

_____  Enclosed is my check for $_______________ (US Dollars only from a USA bank)

_____  Please charge my Visa or Mastercard for $_______________ (U.S. Dollars)

                                                                                                                                                                    

Card Number___________________________16 digits) Expiration Date:_______________(month & year)(MM/YYYY)

 

Signature or typed name for authorization of charge______________________________________________________

 Is your credit card billing name and full address the same as you have given on the first page? _________________________

If not, please provide the name and/or address from the credit card billing.

 NAME, IF DIFFERENT FROM PAGE ONE______________________________________________________________

 NUMBER OF STREET ADDRESS AS IT APPEARS ON YOUR CREDIT CARD BILL__________________________

 FULL ZIP OR MAIL CODE AS IT APPEARS ON YOUR CREDIT CARD BILL________________________________

 

SUBMISSION INFORMATION

 Please submit your completed form and payment:

 By E-mail to   kaygreen@ix.netcom.com

     OR

By Mail to:  Dr. Kay C. Greene, Secretary-General, ICP

                     4701 Willard Avenue, Suite 1621

                     Chevy Chase, MD 20815-4630 USA                                                COMPLETE PAGE 1 ALSO.