Dr. Edith H. Grotberg
ICP President
Email: egrot@ erols. com
4141 N. Henderson RoadSuite
1205 Arlington, VA 22203
Tel: 703 525 9045 Fax 703 351 0782
or:
Dr. Matti K. Gershenfeld
ICP Secretary General
Email: matti@ nni. com
The Colonade, # 1201
100 Old York Road
Jenkintown, PA 19046 USA
Tel: 215-884-4664
Fax: 215-884-4665
The new officers and Board will be:
President
Dr. Edith Grotberg
4141 N. Henderson Road, # 1205
Arlington, VA 22203-2477
Tel: 703-525-9045 Fax: 703-351-0782
eg96@ georgetown. edu
President-Elect
Dr. Natividad Dayan, Pres. -elect
De La Salle University , Couns &
Ed. Dept.
Taft Avenue Manila 01108
Philippines
Tel: 632-724-53-58
bereps@ pacific. net. ph
Secretary
Dr. Joy K. Rice
4Univ. of Wisconsin -Psychiatry
2727 Marshall Court
Madison, WI 53705
Tel: 608-238-9354; Fax: 608-238-7675
jkrice@ facstaff. wisc. edu
Treasurer
Dr. Donna Goetz
355 East Berkshire Avenue 13
Lombard, IL 60148-1763
Tel: 630-617-3583 Fax: 630-617-3735
donnag@ elmhurst. edu
Secretary General
Dr. Matti K. Gershenfeld
The Colonade, # 1201
100 Old York Road
Jenkintown, PA 19046
Tel: 215-884-4664
matti@ nni. com
Past President
Dr. Antoinette D. Thomas
100 de Normandie
St. Lambert PQ J4S 1T4 CAN
Tel: 450-466-9459
antoinettethomas@ videotron. ca
DIRECTORS AT LARGE
Term Expires in 2004
Prof. Roberta Milgram
15 Baram
Kochav Yair 44864 Israel
Tel: 972-050 876948
milgram@ post. tau. ac. il
Mr. Monty Satiadarma
Jl. Hijau Daun 26
Cawang-Jakarta 13340
Indonesia
msthymus@ cbn. net. id
Prof. Ruben Ardilla
Carrera 14 No. 92-67
Bogota 00008 Columbia S. A.
Tel: 571-256-75-27
psycholo@ aolpremium. com
Dr. Anna Laura Comunian
University of Padua
Department of Psychology
Via Venezia 8
Padova 35100, Italy
Tel: 0039 -049-8276-6629
annalaura. comunian@ unipd. it
Term Expires in 2005
Dr. Dietrich Albert
Ruckerlbergguertel 13
Graz A-8010 AUSTRIA
Tel: 43( 316) 380-5118
dietrich. albert@ uni-graz. at
Dr. Margot Nadien
55 Central Park West # 14E
New York, NY 10023-6003
Fax: 212.636.7217
nadien@ fordham. edu
Dr. Sarlito W. Sarwono
Kompleks UI No. 6
Ciputat 15419 Indonesia
Tel 62-21-7270004/ 5
sarwono@ sarlito. com
Dr. Seisoh Sukumune 3609 Obayashi-cho, Asakita-ward
Hiroshoma JAPAN Tel: 81-798-45-9911
seisohok@ mwu. mukogawa-u. ac. jp
Term Expires in 2006
Prof. Amos Alao University of Botswana
PO BOX # 70052 Gaborone, Botswana
Tel ( 267) 390 7893 Fax : 267 395-6958
ALAOAA@ mopipi. ub. bw
Dr. Joan Chrisler Dept. Psych. Connecticut College
270 Mohegan Ave. New London, CT 06320-4196
Tel: 860) -439-2336 jcchr@ conncoll. edu
Dr. Henry L. Janzen 922 Burley Drive
Edmonton T6R 1X3 AB, CANADA
Tel: 780-492-5718 Hank. Janzen@ ualberta. ca
Dr. Pittu Laungani 11 Chelmsford Square
London NW10 3AP England Fax) 0208-451-9911
pillarsofsociety@ aol. com
Financial Officer -Non Board Member
Paula R. Leder The Colonade, # 1201
100 Old York Road Jenkintown, PA 19046
215-884-4664 Fax 215-884-4665 pleder@ nni. com 14
14 Page 15
16
International Psychologist, Vol. 43, No. 4 Page 68 August, 2003
INTERNATIONAL
COUNCIL OF PSY-CHOLOGISTS
CLASSIFICATIONS OF
MEMBERSHIP
MEMBERS
Members are psychologists who
( a) hold or are eligible to hold
membership in a national
psychological association affiliated
with the International Union of
Psychological Science, or ( b) meet
comparable requirements in a
particular country, as determined
by the application review agent,
and ( c) have 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.
ASSOCIATES
Associates are individuals who at
the time of application do not meet
requirements for Membership. The
applicant meets requirements to be
a Member except for ( a) 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
( IUPsyS) recognizes a higher and
lower level of qualification for
different classes of its members.
Associates are those who qualify
at the lower level, or ( b) are
applicants who meet comparable
requirements in a particular
country, as determined by the
membership application
processing agent and approved by
the Board, and ( c) are actively
engaged in professional work,
study, or research that is primarily
psychological in nature.
PROFESSIONAL AFFILIATES
Professional Affiliates are persons
active in a profession allied to
psychology who are interested in
helping to advance the purposes
of ICI.
STUDENT MEMBERS
Student members are ( a) graduate
students, or ( b) full-time
undergraduate students actively
working toward a degree or
certificate in psychology, or ( c) in
an area of study involving major
emphasis on psychological aspects
of a related field of study.
AppIicants for Student
Membership must provide the
name and ADDRESS of their
major professor and their
university, and must include the
anticipated date of the degree or
certificate toward which they are
working.
ENDORSEMENT
REQUIREMENTS
Most applicants should ask two
professional persons to sign as
endorsers on the application blank
or write a letter of endorsement
directly to the ICP Secretariat.
These endorsers should be familiar
with the applicant s training and/
or experience in psychology and
should be members of ICP or be
recognized professional persons
who can be identified by the
membership application
processing committee. An
applicant who is a member of a
national psychological association
affiliated with IUPsyS and who is
endorsed by a current ICP Board
Member or Area Chair need
provide no further endorsement.
An application for membership is
not complete and will not be
processed until the required
endorsements are received. ( If
endorsers are not available, send
complete curriculum vitae with
application. )
Applications/ Dues also may be
Emailed to: pleder@ nni. com or
The International Council of Psychologists Dr. Matti K. Gershenfeld,
Secretary General The Colonade, # 1201 100 Old York Road Jenkintown, PA 19046
USA
Email: matti@ nni. com Tel: 215-884-4664 Fax: 215-884-4665
ICP Website: http:// icpsych. tripod. com
2004 ICP New Membership Application
Last Name________________________
Please read instructions regarding dues amount and membership class.
_ _ _ _ _ Member _ _ _ _ _ Associate _ _ _ _ _ Professional Affiliate _ _ _ _ _
Student Member
PLEASE TYPE
Title: Dr Prof Mr Mrs Ms
NAME:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last name ( Family name) First Name ( given name) Middle Initial
HOME MAILING ADDRESS:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State_ _ _
_ _ _ _ _ _ _ _ ZIPCODE_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Country_ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
TEL Office: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ TEL Home: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _
Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E-mail address: _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PROFESSIONAL ADDRESS ( if different from Mailing Address) :
Position_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Institution/ Practice_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _
Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ City_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State_ _ _ _ _ _ _ _ _ _ _
_ _ _ _
Country_ _ _ _ _ _ _ _ _ _ _
DEGREES OR CERTIFICATES ( Highest appropriate) : Degree, date, major subject,
institution, location.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
STUDENT MEMBER Only: Institution _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Major Profession _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Anticipated degree _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ _ _ _ _ _
EXPERIENCE: Dates, title, institution, location. Your last 2 positions. or last
ten years.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
MEMBERSHIPS IN PROFESSIONAL SOCIETIES: Society name, date of admission, class of
membership.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
TWO ENDORSERS: Names, addresses, and signatures ( See Instructions in Membership
Classes) .
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
If your interest in ICP was encouraged by someone other than an endorser, please
give name ( s) :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
LANGUAGES_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ Date_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ICP Membership year is Jan I -Dec 31. Application/ DUES received after August 15
will be credited for
the following year.
Payment Options: Where and how to send your application and payment appear on
page 2 of the Dues
Payment Form. This New Member Application must accompany your Payment Form. 16
16 Page 17
18
International Psychologist, Vol. 43, No. 4 Page 70 August, 2003
International Council of Psychologists
Matti K. Gershenfeld, Ed. D. , Interim Secretary-General
The Colonade, # 1201 100 Old York Road Jenkintown, PA 19046
Tel: 215-884-4664 Fax: 215-884-4665 USA Toll Free# 1-866-782-5503
Email: matti@ nni. com ICP Website: http: / / icpsych. tripod. com
2004 MEMBERSHIP DUES AND PAYMENT FORM
Name must appear on Page 1 & 2
Member Renewal Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _
NEW Member Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _
ICP MEMBERSHIP FEES ARE DUE BY JANUARY 1, 2004 ( A late fee of $ 10 will apply
after January 10 th )
( Country of Residence Determines Dues Category. Check one. Amounts in US
dollars)
_ _ _ _ CATEGORY A COUNTRIES: : $ 85 ( 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 ( Antigua & Barbuda, Argentina, Bahamas,
Barbados, Brazil, China, Croatia, Cyprus, Czech Republic, Iran, Korea, Malaysia,
Malta, Mexico, Oman, Poland, Seychelles, SIovakia, Slovenia, South Africa,
Suriname, Turkey, Venezuela,
Yemen)
_ _ _ _ CATEGORY C COUNTRIES: $ 23 ( All other countries)
_ _ _ _ STUDENT: Category A $ 23 _ _ _ _ _ _ _ _ _ Category B $ 20 _ _ _ _ _ _ _
_ _ _ Category C $ 15_ _ _ _ _ _ _ _ _ _
( Each year, all students must send name/ address/ phone number of College and
Major , and expected date of graduation with this form. )
_ _ _ PERMANENT MEMBER _ _ _ _ _ LIFE MEMBER
A Suggested Voluntary Contribution of 50% of your Country Category Dues would
help to defray ICP costs to service your membership.
( Note: Life and Permanent Dues Options were Discontinued as of 1999. )
DUES for 2004 Amount $ _ _ _ _ _ _ _
PERMANENT / LIFE MEMBER CONTRIBUTION Amount $ _ _ _ _ _ _ _
GROWTH FUND CONTRIBUTION ( To fulfill ICP objectives and future plans) Amount $
_ _ _ _ _ _ _
DISCRETIONARY SPONSOR FUND ( To help members in extreme economic need. ) Amount
$ _ _ _ _ _ _ _
DENMARK/ GUNVALD GENDER RESEARCH FUND Amount $ _ _ _ _ _ _ _
SUKEMUNE/ BAIN EARLY CAREER RESEARCH FUND Amount $ _ _ _ _ _ _ _
STUDENTS FUND ( To help students in financial distress in A, B, or C countries)
Amount $ _ _ _ _ _ _ _
LATE FEE ( Payment after January 1 st include $ 10 late fee ) Amount $ _ _ _
_ _ _ _
DUES for 2003 which I forgot to pay Amount $ _ _ _ _ _ _ _
TOTAL ( US Funds) $ _ _ _ _ _ _ _ _ 17
17 Page 18
19
International Psychologist, Vol. 43, No. 4 August, 2003 Page 71
MEMBERSHIP FORM -PAYMENT OPTIONS
Page 1 & 2 Must be Submitted for Processing with Payment
Member Renewal Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _
New Member Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _
Please Type Or Print Clearly Please Complete ALL Information.
Title: Dr. _ _ _ _ Prof. _ _ _ Ms. _ _ _ Mrs. _ _ _ Mr. _ _ _
First Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Middle Initial _ _
_ _ _ Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _
E-MAIL Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ ( PRINT in CAPITAL LETTERS or TYPE)
Include your E-MAIL address. It is the primary means of communication and
decreases costs for both ICP
and our Members.
Home Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ City_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _
State _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Zip/ Postal Code_ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ Country _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _
Home Telephone _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ Fax_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _
Office Telephone_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ Fax_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _
TOTAL PAYMENT ENCLOSED ( U. S. Dollars) $ _ _ _ _ _ _ _ _ _ _ ( Return
payment with all completed information.
PAYMENT OPTIONS: Pay By Check or Pay by Credit Card ( Only VISA or MASTERCARD
accepted)
1. POSTAL MAIL: _ _ _ _ _ Send your Membership Form and Payment Form with your
Check* made to ICP
to:
International Council of Psychologists
Mrs. Paula R. Leder, ICP Financial Officer
c/ o Dr. Matti K. Gershenfeld, ICP Secretary-General
The Colonade, Suite # 1201
100 Old York Road,
Jenkintown, PA 19046
* All Checks Must Include a Contact Name and Telephone Number.
2. FAX or EMAIL _ _ _ _ Complete the entire Membership Form ( both pages) and
Credit Card Information
FAX: 215-884-4665 or EMAIL to: pleder@ nni. com
3. CREDIT CARD AUTHORIZATION ( TYPE or PRINT CLEARLY)
Complete and return both the DUES PAYMENT FORM and the CREDIT CARD AUTHORIZATION
I authorize _ _ _ VISA _ _ _ MASTERCARD payment of $ _ _ _ _ _ _ ( U. S.
dollars) to ICP
Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exp.
Date_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
( Requires 16 digits) Month / Year
NOTE: PRINT FULL NAME AND ADDRESS: EXACTLY as it appears on your Billing
Statement from VISA
or MasterCard INCLUDING FULL ZIP/ POSTAL CODE .
Full Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
CompleteAddress_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _
State _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Zip/ Postal Code_ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ Country_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( MM/ DD/ YYYY)
Telephone_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Email_ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _