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  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

E-MAIL: mattikg@comcast.net

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)

 DUES INFORMATION

 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

FULL NAME__________________________________________________________________________________________

PREFERRED MAILING ADDRESS________________________________________________________________________

City_________________________State_______________________Zip/Mail Code_________________Country_________

TELE Home____________________________________TELE Work_____________________________________________

FAX__________________________________________E-MAIL_________________________________________________

HIGHEST APPROPRIATE DEGREE OR CERTIFICATE (All needed = Degree, Date, Major Subject, Institution, Location)

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Student Affiliate applicant—you 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.

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

ENDORSERS

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

your application.)

ENDORSER(S) (one or two—see instructions above): Names, addresses, and signatures

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

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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 orders—all will be returned at member’s 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