APPLICATION FORM FOR MEMBERSHIP

Application for:

(Choose the type of membership you would like to apply for.

Check for the criteria before applying.)

click above to Insert recent photograph

PERSONAL DETAILS:

Name (Block letters):
Date of Birth:	Gender:
Residential Address: (For Postal Communication)
E Mail ID: (Preferred to receive CPSI communication)	@
Mobile Number:	Phone Number:
Present Designation and Official address:

ACADEMIC CREDENTIALS:

DEGREE	SUBJECT	Name of the Institution	Year of Passing
Graduation
Post Graduation
D.M & S.P/M.Phil. C.P/M.&SP
Ph.D

Professional Details:

RCI Registration Status:	RCI – CRR No:

(is essential criteria for obtaining Fellow membership and Professional life membership )

Particulars of Professional Experience

(Specify type: clinical practice / teaching / research in the field of clinical psychology/ psychology)

DESIGNATION	Type	PLACE OF WORK	FROM	TO

Particulars of other professional affiliation:

Areas of Interest:

Payment declaration:

I am sending sum of as membership towards

through Bank Draft/ Cheque/ Online Transfer vide Cheque/ DD No / Transaction Reference Number: dated in favour of “CLINICAL PSYCHOLOGY SOCIETY OF INDIA” Payable at Bengaluru.

Declaration/ Undertaking:

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:

E-Mail ID:	State:	Pin code

Place:

Date:

Signature of the applicant

Instructions:

Kindly fill in the form by clicking on space and insert photograph and signature in the respective space provided by clicking on the space.

Send the filled in form to the Gen. Secretary of CPSI through mail on cpsocietyofindia@gmail.com with the necessary attachments.

Attachments: (Tick Applicable and attach the same)

RCI registration Certificate

Degree certificate of the highest qualification/preferably rehabilitation qualification

Adhaar Card

Student ID / authentication letter (if applying for student membership)

Fee Payment – screenshot/ receipt

Bank Details:

Beneficiary Name: Clinical Psychology Society of India

Current Account No: 41114121499

IFS Code: SBIN 0040675

Bank: State Bank of India, NIMHANS branch.

FOR OFFICIAL USE ONLY

Received Rs	for membership fee _as per article	of CPSI memorandum under the approval of Executive council meeting held on	. Remarks : Admitted / Not Admitted	Class Of Membership: F/F(A)/ PLM /PM/ LAM /AM (A) SM(A) / PM-I

Place :	Date :

Signature

(President, Secretary, Treasurer)