Académique Documents
Professionnel Documents
Culture Documents
membership
When you have completed the form please return it to:
The British Psychological Society
St Andrews House
48 Princess Road East
Leicester LE1 7DR
Queries
e: applications@bps.org.uk
t: +44(0)116 252 9911
Surname
Previous surname
(if applicable)
Forenames
Date of birth
BPS membership
number (if known)
Contact address
(Where no Chartered
Member List address
is entered, this
address will be
available to the
public unless
otherwise indicated
below)
Postcode
This address to be
made public?
Yes
No
Email address
Daytime
telephone
Mobile telephone
Fax number
Start date
Date of award or
expected completion
UNISA
Feb 2002
May 2006
Employment- Please list the principal appointments held OUTSIDE THE UK since obtaining
qualifications in psychology (continue on a separate sheet if necessary). It is often useful to include a CV.
Job title/occupation
Employer
Date from
To
Registration/licensing outside the UK - Please list below any registration or licensing you
hold or have held
Name of registration/licensing authority
Grade of registration/licensing
Date from
To
Proposers - You should not send your form containing payment card details to your proposers. If paying
by card the details should be entered after the form has been signed.
Please give the names and contact details of two psychologists, one of whom should be able to confirm the details
of your professional training and one who will be able to comment on your professional work following training.
I, the undersigned, propose this applicant for Chartered membership/membership of a Division. I certify that to the
best of my knowledge and belief, the information the applicant has given is correct.
Name:
Name:
Address:
Address:
Email:
Email:
Fax:
Fax:
Signature:
Signature:
In signing the form, proposers are certifying that the information given is correct, not that the applicant is definitely eligible.
Declaration
I declare that the information given in this form and any supporting documentation is true and accurate. I have read
the Member Conduct Rules and undertake to abide by and operate within them at all times. The Member Conduct
Rules are available on the Societys website www.bps.org.uk
Signed:
Date:
Communication
E-mail addresses may be used by the Society to communicate with you instead of by post in matters relating to your
membership. Please tick if you also wish to receive messages from carefully selected third parties.
We may also from time to time send material by post from carefully selected third parties. If you do not wish to receive
this, please tick here.
The Society will not sell or give your personal details to any third parties without first seeking your permission or we are
legally instructed to do so under UK law.
Payment
The appended subscription and application fees sheet has details of the amount you need to pay. Please include a
cheque made payable to The British Psychological Society for the relevant fees or confirm the amount and give
your debit/credit card details below. Unfortunately payment for this application cannot be done by Direct Debit.
I enclose a cheque for _____ or please charge my Credit/Debit card
_____
Visa
Amex
MasterCard
Delta
Switch/Maestro
Card number
Valid from: ____/____ Expiry date: ____/____ Issue No (switch only):
____
Non-members
Those applying to join the Society will need to pay 186 (126 annual subscription plus a one off 60
application processing fee).
Current members
There is a one off 40 application processing fee for Chartered Membership.
Divisional membership
If you are applying to join a Division you will also need to enclose payment for that. The rates for each
Division are as follows:
Division
Fee
Clinical Psychology
16
Counselling Psychology
35
30
30
Forensic Psychology
15
Health Psychology
Neuropsychology
15
Occupational Psychology
15
15
15
Mem No:
Referee:
Mem No:
1.
I have known the applicant for years and my relationship with the applicant is
as a supervisor/work colleague/other (please give details).
............................................................................................................................................
2.
To the best of your knowledge is the information given on the application form correct?
Yes
No
If no, please give details (continue on a further sheet if
necessary)
............................................................................................................................................
............................................................................................................................................
3.
Given the criteria (below) and form, do you support the candidates application?
Yes
No
If no, please give details (continue on a further sheet if
necessary)
............................................................................................................................................
4.
Please add additional comments regarding the applicants suitability (continue on a separate
sheet if necessary)
............................................................................................................................................
............................................................................................................................................
Signed:
Date:
Please note: Further information about each Division can be found on our website
www.bps.org.uk/networks/divisions or call the Membership Team on +44(0)116 252 9911
Mem No:
Referee:
Mem No:
1.
I have known the applicant for years and my relationship with the applicant is
as a supervisor/work colleague/other (please give details).
............................................................................................................................................
2.
To the best of your knowledge is the information given on the application form correct?
Yes
No
If no, please give details (continue on a further sheet if
necessary)
............................................................................................................................................
............................................................................................................................................
3.
Given the criteria (below) and form, do you support the candidates application?
Yes
No
If no, please give details (continue on a further sheet if
necessary)
............................................................................................................................................
............................................................................................................................................
4.
Please add additional comments regarding the applicants suitability (continue on a separate
sheet if necessary)
............................................................................................................................................
............................................................................................................................................
Signed:
Date:
Please note: Further information about each Division can be found on our website
www.bps.org.uk/networks/divisions or call the Membership Team on +44(0)116 252 9911
Confidential
Does your impairment mean that you have problems with your usual
activities?
Do you often have to ask for changes to be made in order that you can
take part in activities equally?
Please indicate the adaptations or personal assistance required to enable you
to carry out your daily activities, e.g. provision of a note taker, support worker,
etc.
Gender
Female
Male
Confidential
Ethnic origin - What is your ethnic group?
Choose one section from A to E then tick the appropriate box to indicate your
cultural background
A
White
British
English
Scottish
Welsh
Other, please state below:
Irish
Any other white background, please state below:
Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background, please state below: