INTERNATIONAL COUNCIL OF PSYCHOLOGISTS Page 1 of 2
Dr. Matti K. Gershenfeld, Secretary-General
Secretariat Address: 8302 York Road, B-45 Elkin Park, Pa 19027, USA
ICP WEB SITE: http://www.internationalcouncilofpsychologists.com
2007 MEMBERSHIP DUES STATEMENT
ICP Membership Fees and this Dues Form are due JANUARY 1, 2007
($10 Late Fee applies after January 31, 2007)
Country or Country Area determines Dues Category. Check one. All fees are in US Dollars.
Membership Application 2007
PLEASE WRITE YES IN FRONT OF THE CLASS OF MEMBERSHIP FOR WHICH YOU QUALIFY
__________ A MEMBER is a psychologist who (a) holds or is eligible to hold membership in a national psychological association
affiliated with the International Union of Psychological Science (IUPsyS), or (b) meets comparable requirements in a particular country,
as determined by the application review agent, and (c) has been actively engaged for a period of not less than two years prior to
application for membership in professional work or study that is primarily psychological in nature.
__________ An ASSOCIATE is an individual who at the time of application does not meet requirements for Member. The
applicant meets the requirements for Member except (a) for the two years of qualifying experience; or (b) in those countries in which
the national psychological association affiliated with the International Union of Psychological Science recognizes a higher and lower
level of qualification for different classes of its members, an Associate is one who qualifies at the lower level, and is actively engaged in
professional work, study, or research that is primarily psychological in nature; or (c) are applicants who meet comparable requirements
in a particular country, as determined by the Membership Applicant Processing Coordinator and approved by the Board.
__________ A PROFESSIONAL AFFILIATE is a person who is professionally active in a profession allied to psychology who
is interested in helping to advance the purposes of ICP.
__________ A STUDENT AFFILIATE is a graduate student or full-time undergraduate student actively working toward a
degree or certificate in psychology or in an area of study involving major emphasis on psychological aspects of a related field of study.
PREFERRED TITLE: _____ Dr _____Prof _____Mr _____Mrs _____Ms
PREFERRED MAILING ADDRESS________________________________________________________________________
TELE Home____________________________________TELE Work_____________________________________________
HIGHEST APPROPRIATE DEGREE OR CERTIFICATE (All needed = Degree, Date, Major Subject, Institution, Location)
Student Affiliate applicantyou must provide (1) the name and address of your university, (2) name and address of your major
professor, (3) your anticipated degree or certificate, and (4) your anticipated date of graduation.
1. If you are a member of a national psychological association affiliated with the International Union of Psychological Science
(IUPsyS), and are endorsed by at least one current ICP Board Member and/or Area Chair, you do not need to provide any other
endorsement than the typed full name of that endorser or endorsers on the application.
2. Other applicants: Please ask two professional persons to sign as endorsers on the other side of this application, or have them send
a letter of endorsement directly to the ICP Secretariat (address at the top of this page). These endorsers should be familiar with your
training and/or experience in psychology, and should either be members of ICP or be recognized professional persons who can be
identified by the Membership Application Processing Committee. Your application is not complete and will not be processed until
these required endorsements are received. (If endorsers are not available, please submit a complete curriculum vitae or resume with
ENDORSER(S) (one or twosee instructions above): Names, addresses, and signatures
Page 2 of 2
EXPERIENCE (last 2 positions or last 10 years)(NEED Dates, Titles, Institutions or Companies, and Locations)
MEMBERSHIP(S) IN PROFESSIONAL SOCIETIES (NEED Society Name, Admission Date, and Membership Class)
If your interest in ICP was encouraged by someone other than an endorser, give the name(s):_________________________
Your signature or Typed Name_________________________________________________________Date_________________
PAYMENT: The ICP Membership year is January 1 December 31.
Application and dues received after August 15 will also be extended to the following year.
Country of residence determines dues category. Please write yes in front of one category.
_________ CATEGORY A COUNTRIES OR AREAS: $85 (U.S. DOLLARS)
(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)
_________ CATEGORY B COUNTRIES: $43 (U.S. DOLLARS)
(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)
_________CATEGORY C COUNTRIES: $23 (U.S. DOLLARS) (All other countries)
_________ STUDENT AFFILIATE: _____Category A: $23 US _____Category B: $20 US _____Category C: $15 US
DUES AMOUNT ......... Amount $________
If you would like to also make a contribution, the following choices are available:
_____ MATTI MATTERS GROWTH FUND ........ Amount $________
(Honor former Secretary-General Matti Gershenfeld; to fulfill ICP objectives and future plans)
_____ DISCRETIONARY SPONSOR FUND ....... Amount $________
(Help members in extreme economic need or Sponsor a Category C Member)
_____ SUKEMUNE/BAIN EARLY CAREER RESEARCH FUND .......... ...Amount $________
_____ DENMARK/GUNVALD GENDER RESEARCH FUND ........ .Amount $________
_____ STUDENT SPONSOR FUND ........ ......Amount $________
(Help students in financial need in A, B, or C countries)
TOTAL (US DOLLARS ONLY) ............ ...Total Amount $________
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 ordersall will be returned at members expense.
_____ Enclosed is my check for $_______________ (U.S. Dollars only from a USA bank)
_____ Please charge my Visa or Mastercard for $_______________ (U.S. Dollars)
Card Number________________________________________(16 digits) Expiration Date:_______________(month & year)
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.
FULL ZIP OR MAIL CODE AS IT APPEARS ON YOUR CREDIT CARD BILL_____________________________________
Please submit your completed form to by Mail to: Ms Charlotte Williams, Membership Services, Blackwell Publishing,
9600 Garsington Road, Oxford OX4 2DQ U.K. or email Charlotte at: Charlotte.Williams@oxon.blackwellpublishing.com