ICP Application Form

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 CAPS (Please include your email address. Email is the prime means of communicating with ICP members.)

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:

1. POSTAL MAIL ____________ Send your Dues Form Application & Check made out to ICP TO:

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

2. CREDIT CARD/FAX _________ Enclosed is my Credit Card Authorization (see below)

(You may FAX or EMAIL your Dues Form/Application only if paying by Credit Card)

ICP accepts only payments by VISA or MASTERCARD

ICP Credit Card Authorization Form (Please TYPE or PRINT)

Please Complete Both the DUES APPLICATION and the CREDIT CARD AURTHORIZATION:

I authorize _______ VISA _____ MASTERCARD payment for $ ____________ (U.S. Dollars)

For Membership / Dues, Newsletter, Fees and/or Contributions to the International Council of Psychologists (ICP)

Card Number _________________________________________

Exp Date __________________ (MM /YYYY)

IMPORTANT! Full Name & Exact Address where Credit Card Mails Your Bill. INCLUDING Full Zip/Mail Code.

(ICP is fined every time the address we enter in our credit card machine is different from the address your Credit Card Company lists for you. Thank you.)

EXACT FULL NAME _________________________________________________________

Complete Address: ________________________________________________________

City: ______________________________ State: _______________

Zip/Postal Code: ______________________________

Signature: ____________________________________________________

Date: ________________________________________ (MM/ DD / YYYY)

Telephone: ___________________________ Email: _____________________________

ICP Members in INDIA may pay dues to the ICP Secretariat in U>S. dollars or to the ICP appointed Fiscal Agen in local currency. If paying in local currency, please compute the amount due at the current exchange rate, add 10%, and SEND TO the FISCAL AGENT, INDIA:

Mrs. Darga Parikh

1/50 'KAILASH' Peddar Road

Bombay 400 026 INDIA