I hereby make voluntary application to the American Board of Professional Neuropsychology for professional examination in the specialty of Neuropsychology subject to and in accordance with the rules and regulations of the Board upon successful completion of the examination process and the issuance of the diploma. I agree to be bound by the ethics of professional psychology, not only as currently endorsed by the profession, by also by the standards of practice which shall be adopted from time to time by the American Psychological Association. I agree to be bound by the Bylaws of the Board insofar as they are applicable to me either as a candidate for the diploma or as a Diplomate of this Board. I agree to disqualification from examination or from the issuance of a diploma and to forfeiture and redelivery of such diploma in the event that any of the rules governing examination and issuance are violated by me or for any of the causes set forth in the Bylaws of the Board.
I understand that the program of the Board is entirely voluntary, and I agree to make no claim against the Board, its members, or its agents, for failure to issue to me its diploma or for any action taken in connection with the application. I authorize, whenever it may be deemed appropriate by the Board, the exchange of information concerning my candidacy (before or at any time after action is taken on my application) with the American Psychological Association, with state psychological associations, with state licensing or certifying authorities, and endorsers. I authorize the Board, its members, or its agents to make, on my behalf, investigation as to my character and as to my professional standing as a representative of psychology in the community, and I authorize and invite anyone inquired of for this purpose to respond freely and to report fully and frankly to the Board any matter (without responsibility for the truth thereof) which may seem to them relevant. I waive any claim to examine such data or other information related to the examination process.