You can download this Membership Application in .pdf form to open with Adobe Reader MembershipApplication.pdf but if you don't understand that process, please select all the text below, copy it, and paste it into your word processor. Fill it in and send it to us. Thank you and we look forward to meeting you.
GREATER PITTSBURGH PSYCHOLOGICAL ASSOCIATION
PITTSBURGH, PENNSYLVANIA
APPLICATION FOR MEMBERSHIP
1. Contact Information
______________________ __________________ _________
Last Name First Name Middle Name or Initial
______________________________________________________________________________________
Home Address
______________________________________________________________________________________
City State Zip Telephone
______________________________________________________________________________________
Business or Professional Title at Institution or Organization
______________________________________________________________________________________
Business Address
______________________________________________________________________________________
City State Zip Telephone
E-mail Address: ________________________________________
Preferred address for mailing? __ Home __ Business
Preferred address in the Membership Directory? __Home __Business
2. Academic Training
Degree Date Institution Degree-granting Program Major Field
(Dept. of Psych., School of Education, etc.)
6. Class of membership you are applying for: ___ Member __ Associate __ Affiliate
If applying for Affiliate Membership, answer this section. Otherwise, go directly to Question 7.
A. What college or university are you presently attending? ________________________________________________
B. Are you presently a Graduate student? __ Yes __ No
If so, where? ____________________________
C. What are your fields of study? __________________________________________________
Please attach a letter from your college or university indicating your present academic status.
7. Are you a member of the American Psychological Association? __ Yes __ No
8. Are you a licensed psychologist? __ Yes__ No
If yes, State ______ Lic. # ___________
9. Have you ever been found in violation of an ethics charge by a local, state, or national professional psychological organization or a State Licensing Board? __ Yes __ No If yes, please explain on a separate page or pages.
10. Please give the names of two individuals who can vouch for you as references. They should be members of the Greater Pittsburgh Psychological Association, who are familiar with your past training and present professional activities. If you do not know any current GPPA members, please give the names of two Doctoral-Level Members of the APA, who can be references:
A. ____________________________________________________________________________________
Name Title or Degree Telephone
11. Please include a copy of your Curriculum Vitae with your application.
Annual dues are $60 for Members, $45 for Associates, and $15 for Affiliates. If you are applying after June 30, submit only one-half of the annual dues. Please remit payment of dues with a check made out to GPPA. If the processing of your application cannot be completed for any reason, the check will be returned. If there is an explained financial hardship, a portion of the dues can be waived. In making application for membership, I, the undersigned, hereby give permission for the GPPA Membership Committee to verify the above information and to contact the above-named persons for further information regarding my credentials.
Please mail this application and dues check to:
Larry Glanz, Ph.D., GPPA Membership Chair
155 N. Craig St., Suite 170
Pittsburgh, PA 15213-1574
412-687-8700