The Association of Black Psychologists
7119 Allentown Rd, Suite 203 Ft. Washington, MD 20744
Phone: (301) 449-3082 Fax: (301) 449-3084 Website: www.abpsi.org Email: abpsi@abpsi.org
Join or Renew Online at www.abpsi.org
2013 NATIONAL MEMBERSHIP APPLICATION
Membership Year: January 1, 2013 to December 31, 2013
PLEASE READ APPLICATION GUIDELINES ON REVERSE SIDE
NAME
First
Middle
Last
Suffix
Credential(s)
HOME ADDRESS
CITY
STATE
EMPLOYMENT
-
ZIP CODE
 Fed. Govt.  Local/State Govt.  Institution  Private Practice  Other __________
JOB TITLE
__________________________________
BUSINESS
ADDRESS
CITY
STATE
HOME PHONE
(
FAX
(
)
(
BUSINESS PHONE
)
-
ZIP CODE
)
Ext.
EMAIL
PREFERRED MAILING ADDRESS
 BUSINESS  RESIDENCE
How Long?____________________________
Are you Licensed?  YES  NO If so, Type? _____________________________________
Licensed in which state(s)?____________________________________________________________________
SPECIALTY AREA(S) &/or PRACTICE
TEACHING
RESEARCH
HIGHEST DEGREE EARNED
YEAR
SCHOOL ATTENDED




FIELD OF STUDY
Do you want to be a part of The Media Response Team, where you may be called to speak to the media regarding your area of focus?  YES  NO
Are you a member of an ABPsi chapter?  YES  NO If yes, which one?
______________
If no, and a chapter exists in your area, please include the $25 Member At-Large fee in your total payment.
Would you like to be on ABPsi's referral listing ( a free member benefit)?  YES  NO
If yes, please submit the Psychologist Referral
Registration Form with your application
ANNUAL MEMBERSHIP DUES: Please see reverse for description of membership categories. Students: Include copy of CURRENT Student I.D.





Life Membership may be paid in installments (see reverse)
Life ............................................................................ $2,500.00
Supporting ................................................................ $300.00
Professional .............................................................. $225.00
Associate ................................................................... $225.00
Adjunct ..................................................................... $225.00




Affiliate ................................................$235.00
Graduate Student .............................. $55.00 Psychologist Listing N/A
Undergraduate Student.......................$35.00 Psychologist Listing N/A
Institutional ..........................................$1,500.00
I assume the Rights, Privileges, and Responsibilities of Membership in the Association of Black Psychologists:
Applicant’s Signature
 YES
 NO
Are you a First Time
Member?
Date
PAYMENT METHOD  CHECK/MONEY ORDER
 VISA
 MASTERCARD
 YES
 NO
Do you want to contribute to
ABPsi's Annual Campaign?
$
Amount
 AMERICAN EXPRESS
NAME OF CARDHOLDER___________________________________________________________________________________________________________________
BILLING ADDRESS_________________________________________________________________________________________________________________________
CREDIT CARD NUMBER_____________________________________ CCV CODE____________________ EXPIRATION DATE______________________________
SIGNATURE______________________________________________________________________________
PAYMENT
Membership Fee
_________________
5% Service Charge for credit card payments only
_________________
$25.00 Member-at-large fee
________________
ABPsi Annual Campaign Pledge Donation
_________________
TOTAL AMOUNT
_________________
5% Service Fees on Credit Cards
Supporting
Professional
Associate
Adjunct
Affiliate
Graduate Student
Undergraduate Student
Institutional
$
$
$
$
$
$
$
$
15.00
11.25
11.25
11.25
11.75
2.75
1.75
75.00
GUIDELINES FOR COMPLETING THE MEMBERSHIP APPLICATION






Use your full name as you want it to appear on your membership card.
Be sure to provide the mailing address to where you want to receive your membership materials and publications (especially
students).
A listing of ABPsi’s Chapters is on the website at www.abpsi.org.
An e-mail address is needed to process your membership (for access to on-line membership portal).
Member-At-Large is a category designated for members who do not belong to a local chapter that exists in their area. A $25.00
fee is charged in addition to national dues.
Chapter membership is not permitted without national membership. Chapter membership requires local dues to be paid
directly to the chapter, in addition to paying national membership dues.
Psychologist Referral Program: ABPsi provides a referral service to people looking for African American Psychologists. Participating
psychologists are required to complete the Psychologist Referral Registration Form. This a Free member benefit, valued at $500.00,
open to All Current Members except Student and Institutional Members. This information will also be placed on our website with
your permission. *Please note that it is the member’s responsibility to inform the National Office of any changes to their listing.
MEMBERSHIP
CATEGORIES
LIFETIME:
MEMBERSHIP
REQUIREMENTS
Individual members who wish to make a one-time financial commitment of $2,500
to cover membership dues for the individual's Lifetime. Payment of the $2,500
dues may be paid in installments, and full payment must be made within 3 years.
*A member is not considered to be a Life Member until the Life Member dues
payment of $2,500 is paid in full. Therefore, members must continue to pay
their annual dues in addition to the installment payments, until Lifetime dues
have been paid in full.
INSTITUTIONAL:
Open to institutions/agencies committed to ABPsi’s goals and objectives.
SUPPORTING:
Open to members who wish to make a financial commitment of $300.00, where
$75.00 of this amount goes toward the ABPsi Annual Fund.
PROFESSIONAL:
Individuals who hold a Masters or Doctoral degree in Psychology.
ASSOCIATE:
Individuals who hold a Masters or Doctoral degree in one of the other Behavioral
Sciences.
ADJUNCT:
Individuals hold a Bachelors degree in Psychology and/or one of the other
Behavioral Sciences.
AFFILIATE:
Individuals who are not eligible for other membership categories, but are
committed to ABPsi’s goals and objectives (no voting privileges).
GRADUATE
STUDENT:
Individuals who are currently enrolled at the graduate level in the area of
Psychology (Not eligible for Psychologist Listing Referral Program).
UNDERGRADUATE
STUDENT:
Individuals who are currently enrolled at the undergraduate level in the area of
Psychology (Not eligible for Psychologist Listing Referral Program).
*Students must include a copy of a CURRENT Student ID verifying enrollment.
*As a student you will be a member of the Student Circle. Be sure to visit the
Student Circle section of ABPsi’s website at www.abpsi.org to receive current
information about Student Circle activities.
MEMBERSHIP BENEFITS
Six (6) issues of The Journal of Black Psychology and quarterly issues of ABPsi’s Psych Discourse News Journal; Opportunity to
publish articles in ABPsi publications; reduced Annual Convention registration fees; voting privileges (except for Affiliate and
Institutional members); discounted advertising rates; opportunity to be included on the Psychologist Referral List on the website;
intellectual stimulation; and participation in an organization committed to the physical, mental, and spiritual well-being of African
people.
Please be advised that subscriptions to The Journal of Black Psychology and The Psych Discourse News Journal begin with the next
issue following receipt of membership payment. [Back issues are available for purchase.]