Application for Membership

Application for Membership

NOBPC is a free standing, non-profit educational and service organization dedicated to the furtherance of psychoanalytic understanding. NOBPC offers training in the practice and application of psychoanalysis and psychoanalytically-oriented psychotherapy as well as community outreach, continuing education, research and other activities to deepen the understanding of psychoanalysis, to enrich the human experience and to advance the application of psychoanalysis for the greater human good.
Name*

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**If applicable
Email Address*
Office Street Address*

Street Address

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Postal / Zip Code
Home Street Address

Street Address

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CityState / Province

Postal / Zip Code
Select Preferred Mailing Address*

Office Street AddressHome Street Address
Office Telephone*
Office Mobile Phone*
Home Telephone*
Home Mobile Phone*
Professional Credentials*
Professional Affiliations*
Please provide a brief statement regarding your interest/intent in joining NOBPC.*
What are your professional/clinical interests?*
What are your additional outside interests?*
In what committees or activities would you be interested in being involved? (select one or more)*

MembershipEthicsNominatingClinician AssistantPolicy & ProcedureFinanceOutreach & Continuing Education (includes: Scientific Meetings & Programs, Speaker Series, Film Series, Honorary Mentorship)
Applicants must be in good standing according to the guidelines within their own discipline. If the answer to any of the following questions is yes, please provide a detailed statement of explanation in the appropriate section.
Have you ever been convicted or pled nolo contendere to a felony?*

YesNo
If you answered YES to the question above, please explain below
Has your membership in a state, county, or local professional society ever been revoked, suspended, placed on probation, or restricted in any manner as a result of an ethical violation or for any other reason?*

YesNo
If you answered YES to the question above, please explain below
Have you ever voluntarily surrendered, or did you have suspended, revoked, placed on probation, or restricted in any manner any professional license by any licensing authority?*

YesNo
If you answered YES to the question above, please explain below
Have you ever been the subject of any type of disciplinary action or inquiry by any licensing agency, institution, or society?*

YesNo
If you answered YES to the question above, please explain below
References
Please have two people who are familiar with your professional work complete our letter of recommendation form.
General Membership dues are $240.00 per year.

To pay online click here
When accepted, I agree to abide by the policies and procedures of the NOPBC. *

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Your application will be reviewed and voted on by the Membership Committee and Board of Directors. Thank you for applying!
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Application for Membership

General Membership dues are $240.00 per year.