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2010-2011 Membership Application
Memberships Are Effective Through June 30, 2011
Please select
New member
Renewing member*
Member records update
*For renewing members, the year you first joined NCAPP
Membership type and dues
$45 Standard Membership
$25 Retired Practitioner Membership
$25 Psychology Student Membership
Your full name
Name you go by
Licensure
Licensed Psychological Associate (LPA)
Practicing Psychologist
Other
License date
License status
Active
Inactive
Supervisory level
Level 1
Level 2
Level 3
Highest-level degree
Degree institution
Your specialty
Clinical
Counseling
Educational
School
Other specialty
Degree date
Work setting
Private/Group Practice (01)
Public School System (02)
Educational Institution (03)
Mental Health Center (04)
Prison/Correctional System (05)
Hospital (06)
Non-government health care organization (07)
DEC (08)
Business/industry (09)
Private/Nonprofit Agency (10)
Other work setting (99)
Unemployed
Retired
Business address
County where business is located
Work phone, including area code
Home address
Home county
Home phone, including area code
Mobile phone, including area code
Preferred mailing address for NCAPP correspondence
Business address
Home address
May NCAPP send you email messages? Email is NCAPP’s primary means of communication with members. We encourage you to opt in to our mailing list so you can receive the full benefits of your membership. We respect your privacy and assure you, your address is safe with us. We do not share our email list.
Yes
No
Primary email address for NCAPP messages
Your areas of expertise and possible interests in serving your fellow-LPAs through your membership in NCAPP. Please check all that apply.
Membership development and support
Mentoring students and less-experienced colleagues
Writing for the newsletter, posting on the web site
Continuing education and professional development
Board membership
Fundraising activities and support
Supporting legislative efforts, lobbying
Providing web site technical support (WordPress)
Helping organize and set up meetings and seminars
Other
Comments and/or questions
Dues payment
I am paying my dues online
I am mailing my dues payment
Once you click the above sign-up button to submit your completed Membership Application, you will be taken to a page with directions for paying your dues. Thank you for joining us!
