Member/Associate Application
Please see Instructions for membership requirements and terms.
Contact Information
(*Required field)
Name:*
PrefixFirst*MiddleLast*Suffix
Country:*
Address:*
 
 
City:*
State/Province:*
Zip/Postal Code:*
Email:*
Please reenter Email for verification:*
Date of Birth:* (mm/dd/yyyy)
Gender:* Male Female Transgender
 We require either a work phone number or a home phone number to facilitate follow-up *
 Work Phone:   Ext:       Home Phone:   Ext:       Fax:
Highest Degree in Psychology or Related Field
Highest degree:*
If "other" highest degree, please specify:
Major field of the highest degree:*     Instructions
If "other" major field, please specify:
Degree Month:* (e.g. 03)          Year:* (e.g. 2002)
Institution:*
Department:*
Country:*
City:*
State/Province:*
Current Major Field and Current Employment
Current major field:*
If "other" major field, please specify:
Employment setting:*     
(Select general and details)     		 General setting
Setting details
If "other" employment setting, please specify:
Country where you are employed*:
Position or title:
Department:
Employer, Institution or Firm:*   (Required only in U.S. and Canada)
Employer Zip:*   (Required only in U.S. and Canada)
Employed from Month:* (e.g. 03)         Year:* (e.g. 2002)
Licensure/Ethics
Are you licensed as a psychologist by a state or provincial psychology board?:* Yes No
Country where you are licensed:* Instructions
State/Province where you are licensed:*
If no, are you planning to pursue a license to practice as a psychologist?: Yes No
Have you at any time been convicted of a felony, sanctioned by any professional ethics body, licensing board, or other regulatory body or by any professional or scientific organization?:* Yes No
If yes, please explain:
(Only first 2000 characters will be submitted)
Other Information
Is this your first application for membership in APA?:* Yes No
Former Name (if any):
Affiliate number or former member number(if any): (8 digits, no dash)
What is your ethnicity? (Mark all that apply):
American Indian/Alaskan Native   Asian, or Pacific Islander Caucasian/White  
African American/Black Hispanic/Latino   Other
Your affiliation with APA is considered part of the public record. The information you provided (name and contact information) will be listed in the APA Membership Directory. If you wish to publish only your name in the directory, please place a checkmark here:  

In making this application, I subscribe to and will support the objectives of the American Psychological Association as set forth in Article 1 of the Bylaws, and the Ethical Principles of Psychologists and the Code of Conduct, as adopted by the Association, and I affirm that the statements made in this application correctly represent my qualifications for election, and understand that if they do not, my affiliation may be voided. These may be reviewed at APA's Web site at http://www.apa.org/ethics/code/index.aspx. The bylaws are available at http://www.apa.org/about/governance/bylaws/index.aspx.

Indicate your agreement:* Yes No
    
Questions? Contact APA Membership

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