NJ ASSOCIATION OF BLACK PSYCHOLOGISTS MEMBERSHIP APPLICATION

NEW JERSEY CHAPTER
ASSOCIATION OF BLACK PSYCHOLOGISTS
MEMBERSHIP APPLICATION
Date:

MonthDayYear
Date
Name:
Email Address:
example@example.com
What is your birthday month?
What is your date of birth (day)?
Home Address:
Home phone:
Indicate Preferred Mailing Address
Indicate Preferred Mailing Address
Cell phone:
Office Address:
Office phone:
Highest Degree Earned:
School Attended:
Are you licensed?
License Type/Number
PLEASE CHECK AND FILL IN THE BLANKS FOR ALL THAT APPLY

Other
Please list corresponding specialties, job title, school, or area of research.
Community-based clinical practice:
Private Practice:
Consultant:
Professor:
School psychologist/counselor:
Researcher:
If you would like to be listed in the directory, please follow this link: www.njabpsi.org/referral/
PLEASE SELECT A MEMBERSHIP CATEGORY
Professional Membership: Individuals who hold a Master’s or Doctoral degree

in Psychology. $100.00 annually.

Associate Membership: Individuals who hold a Bachelor’s degree in

psychology, and for those that hold a Bachelors, Masters or Doctoral degree in one of the other Behavioral Sciences (i.e., Social work, Marriage and Family Therapy, etc. $50.00 annually (No voting rights

Affiliate Membership: Individuals who are not eligible for other membership

categories, but are committed to NJABPsi ‘s goals and objectives (i.e., Lawyers, Journalists, etc. $50.00 annually (No voting rights

Student Membership: Students who are enrolled at the graduate or

undergraduate level in the area of Psychology and/or one of the other Behavioral Sciences. $30.00 annually.
MEMBERSHIP CATEGORIES
Pay online or make checks payable to: NJ Assoc. of Black Psychologists
By signing or typing my full name below I assume the Rights, Privileges, and Responsibilities of Membership in the New Jersey Association of Black Psychologists.
*Please note that the application and fee you are submitting is for membership in the NJ Chapter of The Association of Black Psychologists only. For membership in the National Association of Black Psychologist go to: https://abpsi.org/
Signature
DATE

MonthDayYear
Date
**NOTE: Valid ABPsi membership additionally requires payment of national dues.For more information go to: http://www.abpsi.org/forms.html
50 Church Street, Suite # 102, Montclair, NJ 07042

Email: njabpsi@gmail.com — Web site: www.njabpsi.org
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NEW JERSEY CHAPTER

ASSOCIATION OF BLACK PSYCHOLOGISTS

MEMBERSHIP APPLICATION

Please list corresponding specialties, job title, school, or area of research.

PLEASE SELECT A MEMBERSHIP CATEGORY