International Council of Psychologists

Web Site: http://icpsych.tripod.com 
Dues Application Form 

Page #2
 
Must be completed by ALL Members
 
Please TYPE or PRINT) Complete ALL Information and Return with your Dues Payment.
All completed Forms Must Accompany Payment for Processing by ICP.

Check if new address: ________

Title: _______ Full Name: __________________________________________________________________________
First Middle Initial Last
           
Email Address:   _______________________________________________________________
Please TYPE or PRINT in CAPITAL LETTERS  (Please include your email address. Email is the prime means of communicating with ICP members and it decreases costs for both ICP and you.)
 
Home Address: _________________________________________________ City ____________________________
State _______________________________ Zip/Postal Code: __________________ Country: _______________
Home telephone: ____________________________________ Fax: -_______________________
Office telephone: ____________________________________ Fax: _______________________
 
Please return your payment with ALL COMPLETED FORMS.
 
Enclosed is my check for $ ___________________ (U.S. Dollars)

PAYMENT OPTIONS:   _____ Pay by check only (US$ only) OR   ____  Credit Card (Only VISA /MASTERCARD accepted)
1. POSTAL MAIL ____________  Send your Membership Form &  Payment Form with your *Check made to ICP:
 
Mrs. Paula R. Leder, ICP Financial Officer
c/o Dr. Matti K. Gershenfeld, Secretary General
The Colonade, Suite #1201
100 Old York Road
Jenkintown, PA 19046
 
_____ Enclosed is my check for $ ___________ (U.S. Dollars only)
 
______ Enclosed are my completed 2004 Membership/Dues Forms
 

            Note:  Sorry, but we cannot accept Wire Transfers.

 

    *All Checks must be made from a USA Bank, & must include a contact name and telephone number on the check.)
 

2. FAX or Email - You may fax or Email your completed dues statement only if paying by credit card) 

 

Email: pleder@nni.com   Fax: 215-884-4665
 
3. Credit Card Authorization Form (TYPE or PRINT clearly)

Complete and return both the Dues & Membership forms and the Credit Card Authorization for processing.
 
I authorize ______VISA or ______Mastercard  payment for $ ____________ (U.S. Dollars to ICP)
 
Card Number ________/__________/____________/___________/ Expiration date ______________

                                     Requires 16 Digits                                                             MM / YYYY
 

NOTE:  PRINT FULL NAME & ADDRESS  EXACTLY as it appears on your Billing Statement from V or MC - INCLUDING FULL ZIP/MAIL CODE. If incorrect, we / you  will be assessed a “Charge Back” Fee from V or MC in the amount of $20 US$ .

 

  
 

Full Name: _____________________________________________________________________

Complete Address: ___________________________________________________________________

City: _______________________________ State: _____________ Zip/Postal Code _________ Country_____________
 

Signature _________________________________________ Date: ____________________ mm/yyyy

Telephone___________________________ EMAIL____________________________________________

                                                                                                                  Type or Print in Capital Letters