Make your own free website on Tripod.com

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 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