| Last Name |
First Name |
Middle Initial(s) |
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| Mailing Address |
City |
State |
Zip |
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| Phone Number |
Fax |
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x
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| Email Address |
Validate Email Address |
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Personal website address |
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Suppress display of email on web site |
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| Are you a member of CPA?
Yes
No
Are you a member of APA?
Yes
No |
| Membership in the California Psychological Association (CPA) and the American Psychological Association (APA) is recommended, but not required, for membership in CCPA. |
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| Highest Degree Earned |
Area of Concentration |
Month |
Year |
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| Institution |
City |
State |
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| License Number |
Year |
State |
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| List other licences indicating type, state, and date issued:
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| Please indicate the type of membership for which you are applying: |
| Full Member: |
California Licensed Psychologist OR Doctoral Degree in Psychology/Educational Psychology OR Diplomat of the American Board of Professional Psychology ($100 - Before February 28th; $120 – After February 28th) |
$120.00 |
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| New Member: |
Joining between July 1st and October 1st (next year renewal period starts in the Fall) |
$50.00 |
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| Student Member or Psychological Assistant:* |
Please attach a copy of your current school I.D. or Psychological Assistant Certificate |
$50.00 |
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| Emeritus Member: |
Must be retired full-time (additional conditions apply, please contact us) |
$0.00 |
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| Voluntary PAC Contribution: |
The CPA-PAC supports legislative activities to protect and promote the practice of psychology in California. This contribution is a non-deductible expense |
$50.00 |
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| TOTAL DUES: |
$
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* Students members are non-voting until licensed. Requests for hardship dues reduction will be reviewed on an individual basis by the Board. In such cases we request the applicant to volunteer time to committee activities and special projects.
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| PLEASE READ THE FOLLOWING DECLARATION OF PROFESSIONAL ETHICS, AND THEN INDICATE YOUR CONFORMITY BY CHECKING THE BOX BELOW: |
| I have never had action taken against me for unprofessional conduct by a licensing agency or professional organization. |
True
False |
| I have never been convicted in a court of law of a criminal charge. |
True
False |
| I am not currently being investigated by any of the above. |
True
False |
| The information that I have provided is true and verifiable. |
Yes
No
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| I adhere to the APA Code of Ethics. |
Yes
No |
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If you have answered false or no to any of the above, please mail in your application and attach a detailed letter of explanation. You may print the on-line application (next page) or fill out the MS Word or Adobe Acrobat form manually. Mail your completed application to:
Shendl Tuchman, Psy.D.,
2 Crow Canyon Court, Suite 200,
San Ramon, CA 94583 |
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By checking this box, I certify that the information provided in this application is true and verifiable, and that I have read and answered truthfully the Declaration of Professional Ethics above. |
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