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2014NATIONAL MEMBERSHIP APPLICATION

Membership Year: January 1, 2014 to December 31, 2014

Please Read Application Guidelines on Reverse Side

NAME
First / Middle / Last / Suffix / Credential(s)
HOME ADDRESS
CITY / STATE / ZIP CODE / -
Employment / Fed. Govt.  Local/State Govt. Institution Private PracticeOther______/ JOB TITLE / ______
BUSINESS ADDRESS
CITY / STATE / ZIP CODE / -
HOME PHONE / ( ) / BUSINESS PHONE / ( ) Ext.
FAX / ( ) / EMAIL

PREFERRED MAILING ADDRESS  BUSINESS  RESIDENCEAre you Licensed?  YES  NO If so, Type? ______

How Long?______ / Licensed in which state(s)?______
SPECIALTY AREA(S) &/or PRACTICE
TEACHING / RESEARCH
HIGHEST DEGREE EARNED / YEAR
SCHOOL ATTENDED / FIELD OF STUDY
  • Do you want to be a part of The Media Response Team, where you may be called to speak to the media regarding your area of focus?  YES  NO
  • Are you a member of an ABPsi chapter?  YES  NO If yes, which one?______
  • If no, and a chapter exists in your area, please include the $25 Member At-Large fee in your total payment.
  • Would you like to be on ABPsi's referral listing ( a free member benefit)?  YES NO If yes, please submit the Psychologist Referral Registration Form with your application

ANNUAL MEMBERSHIP DUES:Please see reverse for description of membership categories. Students: Include copy of CURRENT Student I.D.
 Life...... $2,500.00 / Life Membership may be paid in installments (see reverse)
 Supporting...... $300.00 /  Affiliate ...... $235.00
 Professional...... $225.00 /  Graduate Student ...... $55.00 Psychologist Listing N/A
 Associate...... $225.00 /  Undergraduate Student...... $35.00 Psychologist Listing N/A
 Adjunct...... $225.00 /  Institutional ...... $1,500.00

I assume the Rights, Privileges, and Responsibilities of Membership in the Association of Black Psychologists:

 YES  NO /  YES  NO / $
Applicant’s Signature / Date / Are you a First Time Member? / Do you want to contribute to ABPsi's Annual Campaign? / Amount
PAYMENT METHOD  CHECK/MONEY ORDER  VISA  MASTERCARD  AMERICAN EXPRESS
NAME OF CARDHOLDER______
BILLING ADDRESS______
CREDIT CARD NUMBER______CCV CODE______EXPIRATION DATE______
SIGNATURE______
PAYMENTMembership Fee ______
5% Service Charge for credit card payments only______
$25.00 Member-at-large fee______
ABPsi Annual Campaign Pledge Donation______
TOTAL AMOUNT______

GUIDELINES FOR COMPLETING THE MEMBERSHIP APPLICATION

  • Use your full name as you want it to appear on your membership card.
  • Be sure to provide the mailing address to where you want to receive your membership materials and publications (especially students).
  • A listing of ABPsi’s Chapters is on the website at
  • An e-mail address is needed to process your membership (for access to on-line membership portal).
  • Member-At-Large is a category designated for members who do not belong to a local chapter that exists in their area. A $25.00 fee is charged in addition to national dues.
  • Chapter membership is not permitted without national membership. Chapter membership requires local duesto be paid directly to the chapter, in addition to paying national membership dues.

Psychologist Referral Program: ABPsi provides a referral service to people looking for African American Psychologists. Participating psychologists are required to complete the Psychologist Referral Registration Form. This a Free member benefit, valued at $500.00, open to All Current Members except Student and Institutional Members. This information will also be placed on our website with your permission. *Please note that it is the member’s responsibility to inform the National Office of any changes to their listing.

MEMBERSHIPCategories / mEMBERSHIP

Requirements

LIFETIME: / Individual members who wish to make a one-time financial commitment of $2,500 to cover membership dues for the individual's Lifetime. Payment of the $2,500 dues may be paid in installments, and full payment must be made within 3 years.
*A member is not considered to be a Life Member until the Life Member duespayment of $2,500 is paid in full. Therefore, members must continue to pay their annual dues in addition to the installment payments, until Lifetime dues have been paid in full.
INSTITUTIONAL: / Open to institutions/agencies committed to ABPsi’s goals and objectives.
SUPPORTING: / Open to members who wish to make a financial commitment of $300.00, where $75.00 of this amount goes toward the ABPsi Annual Fund.
PROFESSIONAL: / Individuals who hold a Masters or Doctoral degree in Psychology.
ASSOCIATE: / Individuals who hold a Masters or Doctoral degree in one of the other Behavioral Sciences.
ADJUNCT: / Individuals hold a Bachelors degree in Psychology and/or one of the other Behavioral Sciences.
AFFILIATE: / Individuals who are not eligible for other membership categories, but are committed to ABPsi’s goals and objectives (no voting privileges).
GRADUATE
STUDENT: / Individuals who are currently enrolled at the graduate level in the area of Psychology(Not eligible for Psychologist Listing Referral Program).
UNDERGRADUATE
STUDENT: / Individuals who are currently enrolled at the undergraduate level in the area of Psychology(Not eligible for Psychologist Listing Referral Program).
*Students must include a copy of a CURRENT Student ID verifying enrollment.
*As a student you will be a member of the Student Circle. Be sure to visit the Student Circle section of ABPsi’s website at to receive current information about Student Circle activities.
MEMBERSHIP BENEFITS

Six (6) issues of The Journal of Black Psychology and quarterly issues of ABPsi’s Psych Discourse News Journal; Opportunity to publish articles in ABPsi publications; reduced Annual Convention registration fees; voting privileges (except for Affiliate and Institutional members); discounted advertising rates; opportunity to be included on the Psychologist Referral List on the website;intellectual stimulation; and participation in an organization committed to the physical, mental, and spiritual well-being of African people.

Please be advisedthat subscriptions to The Journal of Black Psychology and The Psych DiscourseNews Journal begin with the next issue following receipt of membership payment. [Back issues are available for purchase.]