ABPP Annual Attestation for Not Current/Archived Specialists

(If you are a current specialist, please use the Active/Retired form)

ABPP is an active credential that requires annual renewal and associated attestation and fee. The Annual Attestation and Fee is due January 1st; if not submitted by March 31st, your ABPP status will expire and will be reported as such when organizations request verification. Reinstatement can be accomplished by submitting the Annual Attestation and all applicable fees (which include any late fees and prior years fees).

Board Specialist Directory Information: can also be updated on the Member Login Portal of the ABPP website

Name: Degree:

Company:

Address:

City, State, Zip: Country:

Phone: Phone: Phone:

Email: Repeat Email:

Are you a member of: National Register: Hold a CPQ: APA Member #:

States/Prov. Licensed in (list all): Please send future attestations as a hard copy:

Please chose the appropriate option below:

Not CurrentStatus (Your last attestation was submitted in 2016 $395* Active or $125* Retired

*(these fees include the fees for 2017 & 2018 and late fee)

Archived Status (Your last attestation was submitted in 2015 or ealier $500** Active or $150** Retired

**(these fees include fees for prior years and late fee)

ABPP Foundation Donation* $ *All donations will be applied to the Foundation General Fund – to donate to other funds donate online at 3577All contributions made to the ABPP Foundation are recognized by the IRA as 501(c)(3) charitable organization and are tax deductible. The ABPP Foundation depends upon voluntary contributions to sustain its mission which includes the support of ABPP specialty board certification through promotional activities that include scholarship awards, professional development opportunities, and educational programs. The ABPP Foundation Web page link on the ABPP home page provides additional information regarding the recognitions associated with all levels of contributions.

Method of Payment:

Card Number: Expiration Date: CVV: Card Holders Name/Signature*:

*By typing your name above, you agree that this is valid as your signature.

Attest:(please click all that apply)

I have not received any professional misconduct or ethical violation judgments against me by the APA, CPA or any affiliated state, provincial or territorial psychological association or licensing board which have not been previously disclosed to ABPP.

I no longer derive income from working as a psychologist. I am electing to maintain my ABPP Certification in Retired Status.

I actively maintain my practice of professional psychology in my specialty and hold valid statutory recognition in the jurisdiction(s) of my practice.

I agree that ABPP certification is an active credential that requires annual renewal, an associated attestation, and a fee (currently $185/year).In order to remain active and to use the ABPP credential, I also agree to pay all required annual fees assessed by the American Board of Professional Psychology, Inc.

MOC statement: Board Certified Specialists who are certified after January 1, 2015 must successfully maintain their certificate every ten years. Board Certified Specialists who are certified before January 1, 2015 are encouraged to maintain their certificate through demonstration of ongoing competent practice every ten years, but may waive this obligation and maintain their certificate

Please read the following statements and sign below: I agree that I shall advise the Board of Trustrees (BOT) within thirty days of the occurrence of the following events: my psychology license in any jurisdiction is revoked, suspended, restricted, subject to material conditions, or voluntarily relinquished; or a governmental body, the American Psychological Association, the Canadian Psychological Association or any affiliated state, provincial, or territorial association, determines that I have committed professional misconduct, or violated material rules of such body. This reporting obligation exists regardless of the pending outcome of any appeal or other proceedings related to the triggering event.

We want to advise you that if the matter you report is relatively minor, ABPP will simply note your cooperation in the reporting process. However, if that matter is major, it will be reviewed by the Ethics Committee of the American Board of Professional Psychology.

I hereby attest that the proceeding statement and any attached information is true, complete, and accurate to the best of my knowledge and belief.

Signature*: *By typing your name, you agree that this is valid as your signature.