Membership Application Form

Name*

First NameLast Name

Professional Degree*

Organization/Institution

Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Office Telephone*

Area CodePhone Number

Fax

Area CodePhone Number

E-mail*

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Telephone

Area CodePhone Number

Are you renewing your GMPS membership or are you a new applicant?

Renewing my GMPS membershipApplying for new memberhsip

A. Credentials*

B. Which Arizona Board regulates your professional practice?*

C. Arizona License/Certificate Number

D. Are you a Member of the Arizona Psychological Association?

E. Are you a Member of the American Psychological Association?

F. Education (please list the institution, degree, program and graduation date)*

By submitting this document, Psychologists (applicants and renewals) attest to the following:

Ethics Declaration: Granite Mountain Psychological Society is associated with the Arizona Psychological Association and the American Psychological Association. Members of the Granite Mountain Psychological Society support the objectives of the American Psychological Association as set forth in Article 1 of their Bylaws. The Granite Mountain Psychological Society has adopted the Ethical Principles of Psychologists and Code of Conduct of the American Psychological Association. By signing this application, you agree to adhere to the principles contained within that Code.

Copies of the APA Bylaws and/or Ethical Principles are available from the APA, 750 First St., NE, Washington, DC 20002-4242 upon request.

Please be sure to:

Provide complete information. Incomplete information will delay processing of your application.
You may pay online using the below link or enclose your check, payable to the Granite Mountain Psychological Society. Checks may be mailed to: Doug Bergstrom, PhD, 1042 Willow Creek Rd., Ste. A101-421, Prescott AZ 86301-1673

Granite Mountain Psychological Society by-laws state that members have until October to renew and that after that time they will be dropped.

Full Membership in the Society is open to persons who:

1) Hold a graduate degree in psychology or a related field that is mostly psychological in nature, and

2) Are currently, intend to or have been professionally active in psychology or a related field that is mostly psychological in nature, as evidenced by

a) licensure from the relevant State Board or

b) employment as a practitioner, educator, or researcher in psychology or a related field that is mostly psychological in nature, and

3) Adhere to the ethical principles and code of conduct articulated by the national association that represents their profession.

Full Members have voting privileges and can hold office in the Society.

Affiliate Membership in the Society is open to:

Student affiliates. A student pursuing a degree in a program that is mostly psychological in nature. Student Affiliates, please provide a copy of your student identification card or a letter from a faculty member regarding your status.

Community affiliates – individuals who show an interest in the purpose of the society.

Membership in the Society shall be granted upon determination that an applicant has met the criteria for membership.

Student Affiliates, please provide a copy of your student identification card or a letter from a faculty member regarding your status.

New members, please attach a copy of your license and evidence of its current status.

To pay online, click your membership category. To pay by check, click the button at the bottom of the page.

Full Member (annual)$45.00

Full Member (for applications submitted January through June)$45.00

Student Affiliate$25.00

We have scholarships available for student members. If you would like to join as a student member, please contact the Membership Secretary, Dr. Bergstrom, at 520-369-3885 or email him at bergyblues@gmail.com.

Student Affiliate (for applications submitted January through June)$10.00

Community Affiliate$25.00

Community Affiliate (for applications submitted January through June)$10.00

Granite Mountain Psychological Society Membership Application/Renewal

By submitting this document, Psychologists (applicants and renewals) attest to the following: