Referred By:______
PLEASE TYPE OR PRINT ALL INFORMATION
Your full name: ______Informal Name: ______
Address (Home or Work?): ______
City/State/Zip: ______County______
Work Phone: ______Home (or cell) phone: ______
Email: ______Website:______Facebook page for organization:______
Date of birth: ______Degree: rPhD rPsyD rEdD r EdS r MS Year Granted: ______
Institution/City/State: ______Department: ______
Major Specialization (as stated on your transcript): ______
Was graduate program APA approved at the time of graduation? rYes rNo
rLicensed as a psychologist in the state of Florida. License number PY______Year Issued: ______
rLicensed as a psychologist outside the state of Florida: License number: ______State: ______Year Issued: ______
rLicensed in another profession in this or another state: License number: ______State: ______Year Issued: ______
rMaster’s degree in Industrial/Organizational or School Psychology. (Affiliate member only)
rDiplomat of ABPP. Year Awarded: ______rDiplomat of ABPN. Year Awarded: ______
rMember or Fellow of APA. Division(s): ______
Do you have a pending or past complaint against your license, or have a restriction placed upon a license in any jurisdiction?
rNo rYes (attach detailed explanation on separate sheet, including case number and disposition)
WHAT IS THE ANNUAL COST?
Regular/Licensed (in FL) Members - $354/year
1st Year Licensed $187 Out of State Members (Lic. as Psychologist in FL & another state, living in another state) $215
2nd Year Licensed $244 Senior Psychologist (65 or over and has been a member of a state PA for at least 20 years) $212
3rd Year Licensed $302 Semi-Retired (65 or over and has been a member of a state PA for at least 5 years, who continues to be licensed or employed less than 20 hrs. per week) $142
4th + Year Licensed $354 Retired Members (65 or over, has been a member of a state PA for at least 5 years, no longer active) $71
Associate Members $221 Active Duty Military Members (Service & Rank______) $164
(Not Licensed as a psychologist in FL) Affiliate Members (MS in I/O or School Psych) $354
Federal Members (Lic. as Psychologist in another state, works w/VA, military or Fed. Govt. agency) $354
DIVISIONS (Optional):
rChild, Adolescent & Family Division $10 rForensic Psychology Division $10
rNeuropsychology Division $10 rWomen’s Issues Division $10
rMedical Psychology Division $10
FPA Dues ______(From above)
Divisions (Optional) $10 per division x _____ (number of divisions) = $______
Sustaining Membership (Optional) $99
General Political Committee donation (Optional) $______
TOTAL MEMBERSHIP FEES $______
METHOD OF PAYMENT
r Check # (payable to FPA) ______r Visa r MC r Amex r Discover
Name on credit card: ______Card #: ______
Expiration: ______*Security Code: ______Signature: ______
(*Security code for V/MC and Discover is a 3-digit # on the back of the card. Amex has a 4-digit # on the front of the card.)
Regular members will be automatically renewed next year if using a credit card.
rI do not wish to be automatically renewed for next year.
rI agree to abide by the ethical principles set forth by the American Psychological Association and I certify all statements made herein are true and accurate to the best of my knowledge and belief. I understand that my application is subject to review by the FPA Membership Committee. I understand that by joining FPA, I grant FPA permission to communicate with me in any manner, including by emailing me at the email address reflected above.
Signature of Applicant: ______Date: ______
Note: Dues to the Florida Psychological Association are non-refundable.
Note: Dues to the Florida Psychological Association are not deductible as a charitable contribution for tax purposes, but may be deductible as an ordinary and necessary business expense. A portion of the dues, however, is not deductible as an ordinary and necessary business expense because the Association engages in lobbying activities. FPA estimates that 13% of dues are allocated to lobbying activities and are nondeductible. If you have any questions, please contact the FPA Central Office, 850-656-2222.
The Florida Psychological Association, 408 Office Plaza Drive, Tallahassee, FL 32301; Fax: 1-850-344-9085.
REV. 10/25/2017