Psychological Association of the Philippines

Room 208, Second Floor, PSSC

Diliman, Quezon City
Tel./Fax: 453-8257 E-mail add: pap_1962_08@yahoo.com
MEMBERSHIP APPLICATION FORM

( ) New Approved Category: _________________________

PERSONAL INFORMATION

Home
Name:Address: Email Address:
Surname First Name Mobile Number:
Middle Name Nickname
Sex: Landline Number:
Please
If Certified Specialist, please check all
If Licensed, please indicate type: that applies:
( ) Male ( ( ) Psychologist (RP) Membership in Divisions &/or
( ) Female Date Issued: ____________ Specialty Interest Group, please choose ( ) Assessment
ID Number: _____________ only 3 and rank accordingly: ( ) Clinical
Resolution No: __________ ____ Assessment ___MHPSS ( ) Counseling
( ) Psychometrician (RPm) ____Developmental ___LGBT ( ) Developmental
Date of Birth: Date Issued: ____________ ____Clinical ____Teaching ( ) Educational
ID Number: ____________ ____Counseling ( ) Industrial-Organizational
Resolution No: __________ ____Educational ( ) Social
m d y ____IO
m d y ____Social
If NOT Certified Specialist, please indicate area
of specialization:
___________________________

EDUCATIONAL BACKGROUND
Units Year
Degree Major Specialization School/Institution
Completed* Graduated

*State the number of units completed in a degree program if currently working for a degree
PROFESSIONAL EXPERIENCE
Year
Position/Title Institution Contact Number Nature of Work
Employed

Please check which PAP activities you wish to be invited to or
 Conference Management (registration, program, etc)
 Finance committee (sponsorships, fundraising, etc)
 Research (capability building workshops, etc)
 Teaching (capability building workshops, etc)
participate in:
 Outreach (disaster response, psychological first aid, etc)
 Certification (accreditation of CPE providers & programs, etc)
 Awards (evaluation of criteria, judging, etc)
 Public awareness/advocacy (writing columns, giving media I interviews, etc)

Please attach
a) Transcript of Records (TOR) for Non RP/RPm applicants b) Licensure ID for RP and RPm (for those with licensure)
In making this application, I subscribe to and will support the objectives of the Psychological Association of the Philippines as set forth in its
Constitution and By-laws 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 and understand that if they do not, my affiliation may be
voided.

Date Signature

PAP shall be posting the names and contact email of its members who are licensed and certified. Should you wish NOT to have any contact information released or
made public at any time, please check here  ( ).