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Personal Details

Date of Birth: Your Age: Gender * SelectmalefemalePrefer not to Say Residential Address * City* State* Country* PIN Code* Email ID * Mobile (please add country code)* Phone

Present Work Details

Designation * Organization Name * Address for Correspondence *

Academic Credentials

Graduation

Course Name * Name of Institution / University * Year of Passing *

Post Graduation

Course Name * Name of Institution / University * Year of Passing *

Professional Qualification:

Courses Name* SelectDiploma in Medical PsychologyDiploma in Medical & Social PsychologyM.Phil. Medical & Social PsychologyM.Phil. Clinical PsychologyPsyD Clinical Psychology Name of Institution / University * Year of Passing *

Ph D. / Other Course

Course Name * Name of Institution / University * Year of Passing *

Professional Details

RCI registration Status
ActiveNot-ActiveApplied forPre-CRRNot Registered

RCI CRR number

Areas of Professional Interest

Declaration

I hereby certify that the particulars given above are true to the best of my knowledge.

I am interested in the aims and objectives of CPSI and undertake to abide by the rules and regulations during the tenure of my relationship.

I am attaching the copies of my professional degree certificates to substantiate the qualification required for the membership category applied for.

I agree to receive updates or notification regarding the activities or events of CPSI.

Note for applicants

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