LogoABPsi

Professional and Student Membership

The Association of Black Psychologists

PO BOX 2731
Culver City, California 90231-2731
Phone: 213-537-SCABPsi (7222); Website: www.scabpsi.org; Email: scabpsi@gmail.com

 

2015-2016 LOCAL NATIONAL MEMBERSHIP APPLICATION

(Membership Year: August 1, 2015 to July 31, 2016)

Please indicate:
□ Mr.   □ Mrs.
□ Ms.   □ Dr.

      “  NEW    “ RENEWAL
                                                                                                       PLEASE TYPE OR PRINT

NAME:

____________________________________________________________________________________________________________________________________
 

First

 

Middle

 

 

Last

 

 

HOME ADDRESS:

_______________________________________________________________________________________________________________

CITY:

_______________________________

STATE:_____________________

 

ZIP CODE:

 

-

_______________

COMPANY/AGENCY:

_______________________________________________________________

JOB TITLE:

____________________________________________

BUSINESS ADDRESS:

_______________________________________________________________

CITY:

______________________________________

STATE:______________________

 

ZIP CODE:

 

-

______________

HOME PHONE:

(                  )___________________________

BUSINESS PHONE:

(                  )       _______________________       Ext._________

FAX :

(                  )____________________________

EMAIL:____________________________

___________________

PREFERRED MAILING ADDRESS:    “ BUSINESS     “ RESIDENCE


PRIVATE PRACTICE?   “  YES       “  NO

STATE(S) OF LICENSE:

________________________________

SPECIALTY AREA(S): (see list of specialty codes) PRACTICE:

____________________________________________

____________________________________________

TEACHING:

_____________

RESEARCH:

_____________

HIGHEST DEGREE EARNED:

_________________

YEAR:

_________________

 

 

 

SCHOOL ATTENDED:

____________________________________

FIELD OF STUDY:______________________

 
  • Are you a member of an ABPsi chapter?   “ YES      “  NO    If yes, which one?______________________________________________________________________
  • How long have you been a member?  ___________Month    ____________Year
  • Are you willing to serve as a Jegna (mentor) to a student member?   “ YES      “  NO
  • Would you like to be on ABPsi referral listing?   “  YES       “   NO   If yes, please complete ABPsi’s Psychologists Referral Registration Form.                            (NOTE: There is a $100.00 fee to participate in this program.)
  • Are you employed with the following:

“  Federal Government    “  Local/State Government    “  Educational Institution    “  Private Practice    “  Other __________________________________________


ANNUAL MEMBERSHIP DUES: Please see reverse for membership categories.  Students: Include copy of CURRENT Student I.D.

“  Life.................................................................... $2,500.00

Life Membership may be paid in installments (see reverse)

“  Supporting........................................................ $250.00  

“  Affiliate............................................................. $160.00

“  Professional...................................................... $150.00

“  Graduate Student............................................. $50.00

“  Associate........................................................... $150.00

“  Undergraduate Student.................................... $30.00

“  Adjunct............................................................. $150.00

“  Institutional...................................................... $300.00

 

  I assume the rights, privileges, and responsibilities of membership in the Association of Black Psychologists.

______________________________________

 

___________________

 

___________________________________

 

________________

Applicant’s Signature

 

Date

 

Sponsor’s Signature (new members)

 

Date

PAYMENT METHOD:   “  CHECK/MONEY ORDER     “  VISA     “  MASTERCARD     “  AMERICAN EXPRESS
NAME OF CARDHOLDER:___________________________________________________________________________________________________________________
CREDIT CARD NUMBER:______________________________________________________________________ EXPIRATION DATE___________________________
SIGNATURE______________________________________________________________________________
PAYMENT:             Membership Fee                                                                       _________________
                                5% Service Charge for credit card payments                        _________________
                                Member-at-large fee (no local chapter in your area) of $25.00 _______________
                                Referral Listing Fee of $100.00                                             _________________
                                TOTAL AMOUNT                                                                  _________________

                                                                        INSTRUCTIONS FOR COMPLETING THE MEMBERSHIP APPLICATION
  1. Use Full Name as it appears on your method of payment.
  2. ADDRESSES: Be sure to include the city, state and zip code.
  3. Chapter affiliation is available on the ABPsi’s Chapter Presidents Listing and website at www.abpsi.org.
  4. TELEPHONE NUMBERS: Be sure to include the AREA CODE.
  5. All new members are required to have a current ABPsi member sign as a sponsor.  Please check with your local chapter, educational institutions, or regional representative.
MEMBERSHIP
Categories

MEMBERSHIP

Requirements

LIFE:

Members who wish to make a one-time financial commitment of $2,500.  Payment of the $2,500 commitment can be paid in installments.  Full payment must be made within 3 years.
*A member is not considered to be a Life member until the financial commitment of $2,500 is paid in full.  Therefore, members must continue to pay their annual dues, in addition to the installment payments, until the commitment has 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 $250.00

PROFESSIONAL:

Masters or Doctoral degree in Psychology

ASSOCIATE:

Masters or Doctoral degree in one of the other Behavioral Sciences

ADJUNCT:

Bachelors degree in Psychology and/or one of the other Behavioral Sciences

AFFILIATE:

Not eligible for other membership categories (no voting privileges), but committed to ABPsi’s goals and objectives

GRADUATE
STUDENT:

Currently enrolled at the graduate level in the area of Psychology

UNDERGRADUATE
STUDENT:

Currently enrolled at the undergraduate level in the area of Psychology

 

*Students must include a copy of a CURRENT Student ID indicating enrollment.
*As a student you will be a member of the Student Circle.  The 2003-2004 Student Circle Chairperson, Tima Smith can be reach by email at funmi5@hotmail.com. Also, visit the Student Circle section of ABPsi’s website at www.abpsi.org to receive up to date information on Student Circle information and activities.

General Membership Information

  1. Member-At-Large: designated for those members who have no local chapter in their area.  A $25.00 fee is charged in addition to National dues.  This fee is half of the standard chapter fee of $50.00.  As a Member-At-Large your Regional Representative will supply you with all ABPsi local and national information and activities.
  2. Chapter membership is not permitted without National membership.  Chapter fees are to be paid directly to the chapters.
  3. Psychologist Referral Program: ABPsi provides a referral service to consumers looking for African American Psychologists.  Participating psychologists are required to complete the Psychologist Referral Registration Form.  There is a fee of $100.00 to participate in this program.  This information will also be placed on our website with your permission.
  1. Automatic Renewals:  With your signature you authorize ABPsi to automatically charge your annual membership to the credit card account listed on the front.  The automatic renewal of your membership will therefore continue annually unless cancelled in writing by either party.
MEMBERSHIP BENEFITS

Quarterly issues of The Journal of Black Psychology and monthly issues of ABPsi’s Psych Discourse; reduced Annual Convention registration fees; voting privileges (except for Affiliate members); opportunity to participate in the Psychologist Referral Program for a fee of $100.00; Jegnaship (mentorship) opportunities; intellectual stimulation; and, participation in an organization committed to the physical, mental, and spiritual well-being of African people.

Please be advised the Journal of Black Psychology subscription begins the quarter following membership payment; Psych Discourse subscription begins the month following membership payment.  [Back issues are available for purchase.]

DOWNLOAD MEMBERSHIP APPLICATION 2015-16

 

IMPORTANT: PLEASE NOTE, YOU CAN PAY DIRECTLY TO PAYPAL YOU MEMBERSHIP DUES FOR PROFESSIONALS AND STUDENTS BY FOLLOWING THE LINK BELOW.

PLEASE DOWNLOAD APPLICATION AFTER FILING OUT AND E-MAIL SCABPSI@GAIL.COM OR MAIL DIRECTLY TO SCABPSI FOR RECORDING!!!

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