NEW MEMBERSHIP APPLICATION |
| Membership Cost: |
Regular: $100
Student $25 |
| *First Name: |
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| Middle Name/Initital: |
(optional) |
| *Last Name: |
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| Degrees: |
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| ADDRESS NOTE: |
Enter the address you want SBCPA to use for communicating with you. It can be your home or private address. This address will not be made public unless you choose to make it so. You will have a chance to enter your office address(es) after you membership is accepted. |
| Address: |
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| City: |
State:
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| Zip: |
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| Home Phone: |
(format: 415-555-1212) |
| Office Phone: |
(format: 415-555-1212) |
| Fax: |
(format: 415-555-1212) |
| *Private E-mail: |
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| CA License: |
Do you have a California psychology license?
(includes registered psychological assistant) |
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License #
(or registration number - optional for students) |
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License Type
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If you are a registered psychological assistant or student enter the name of your supervisor:
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| Highest Degree: |
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| Institute that granted this degree: |
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| Special Certifications: |
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| Are you a CPA member? |
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| Are you an APA member? |
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| *Choose a User name: |
(no spaces - letters and numbers only) |
| *Choose a Password: |
(no spaces - letters and numbers only - 4 to 12 characters) |
| Special Instructions for the Membership Administrator: |
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After pressing submit you will have the option of paying with a credit/debit card via PayPal or mailing a check to: SBCPA, P.O. Box 24018, Santa Barbara, CA 93121
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Change Image |
| Write the characters in the image above |
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| *required fields ( first and last name, email, user name and password choices) |
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(any problems email treasurer@sbcpa.org)
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| By clicking the "Submit" button below you hereby agree to abide by the most current ethics code as published by the American Psychological Association. |
