The Australian College of Clinical Psychologists

Initial Application for Membership

Tax Invoice (ABN: 56 841 181 577 - ARB: 072 887 640)

Title	First Names:			Surname
Street Address
Suburb
State			Postcode

Postal Address
Suburb
State			Postcode

Work Address
Suburb
State			Postcode

Contact details
Home Phone		Mobile
Work Phone
Fax
Email

Branch you are joining _____________________________________ or Remote Membership

Name of person who introduced you to the College? ________________________________

Please tick the category of College membership for which you are applying:
Student Membership		Annual fee: $99. You must be a full-time undergraduate student of psychology. A photocopy of your current student card must accompany this application.
Training Membership		Annual fee: $298. You must be an intern/probationary psychologist conditionally registered with an Australian State or Territory Psychologist’s Registration Board.
Associate Membership		Annual fee: $298. You must be a psychologist, fully registered with an Australian State or Territory Psychologist’s Registration Board, and be engaged in a minimum of six hours per week of clinical practice . After one years Associate Membership suitable candidates will be offered full membership to the College
		Concessions to the above fees are available upon written application, for those who are engaged mainly in unpaid or voluntary clinical employment.
Psychology qualifications	A photocopy of your qualifications and any relevant academic transcript should accompany your application. These will be retained for your personal file. Do not send original documents.
Qualification			Year gained	Institution

Details of registration(s)
State		Level of registration
Date of registration		Registration number
Psychological employment history with dates (attach extra pages if needed)
	Position		Clinical contact hours per week
Current








Payment details: If not a student application, please forward your fee inclusive of a $30 initial administration fee. If your application is unsuccessful for any reason, the balance (minus the $30 initial administration fee) will be promptly refunded. Enclosed is my fee for: $_________ Please tick one: o Cheque made out to "The Australian College of Clinical Psychologists" o Please debit the prescribed sum from my: MasterCard o Visa card o Card Number: o o o o o o o o o o o o o o o o Card expiry date: o o o o Name on card (please print): ________________________________________Date:____/____/____ Signature of cardholder: ______________________________________ Please register by forwarding your application to your nearest Branch (see www.accp.org for details. You will then be contacted by a Member of that Branch’s Executive. Endorsement of Member of Branch Executive______________________ (signature)
Declaration:

I ___________________________________________wish to apply for membership of the Australian College of Clinical Psychologists. I declare the above information to be true and correct. Upon acceptance of this application, I agree to abide by the rules and requirements of the College.

Signature

Date