NDPA - Application for Membership

Contact Information

First Name*

Middle Initial

Last Name*

Highest Degree*

Date Received*

Professional Position/Title*

Facility/Institution*

Preferred Address*

City*

State*

Zip Code*

E-Mail*

Email address will be used as login email address

Office Phone*

Home Phone

Home Legislative District #*

This item must be completed for your application to be processed, Find your Legislative District

Are you a licensed psychologist?*

Yes
No

Are you a member of APA?*

Yes
No

Membership Categories and Qualifications

Membership type*

Please indicate the category of membership you are applying for and the qualifications you meet

Full (Practitioners and Academicians) - $100.00
Associate - $25.00
Student - $10.00

Optional

Sustaining Membership:- Any member who increases his/her membership investment by an additional $100.00
Support for Legislative Advocacy:- Suggested amount: Equivalent of 1 day's pay.

Sustaining Membership - $100.00

Support for Legislative Advocacy

Background Data

Please attach a curriculum vita or statement outlining your education, professional experience, membership in other professional organizations, licensure/certification/registry status, research, publications, etc.

Login Information

Confirm Email
Password
Confirm Password

Professional Ethics Declaration

This section MUST be completed

Have you had any action taken against you by an employer, professional or related organization, or a state licensing agency?*

Yes
No

To your knowledge, are you presently under investigation by any of the above agencies or organizations?*

Yes
No

Have you ever been found or pled guilty of a criminal charge (excluding traffic offenses) or liable in a civil action brought against you by any court?*

Yes
No

Applicant’s Statement

In making this application for NDPA membership, I subscribe to and will support the objectives of the Association — “to advance psychology as a science, as a profession, and as a means of promoting human welfare” – and agree to abide by the ethical principles of NDPA. I hereby absolve NDPA, its officers and staff, Board of Trustees, Members, and Affiliates from damages or any other liabilities resulting from unfavorable action on my application or from disciplinary action or expulsion under the provisions of NDPA bylaws. The statements made in my application are true and complete. I authorize NDPA to contact my references and investigate my credentials. Unless I notify NDPA to the contrary, I authorize my name and address to be made available to outside individuals and organizations as part of NDPA’s mailing list.

I Agree to the Above Statement*

Signature*

Application for Membership

Contact Information

Membership Categories and Qualifications

Background Data

Login Information

Professional Ethics Declaration

Applicant’s Statement

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