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North Dakota Highway

Membership Registration Form

Type of Degree
Clinical
Counseling
School
Experimental
Other
Are you a licensed psychologist?
Yes
No
Are you a member of APA?
Yes
No

Professional Ethics Declaration

Have you had any action taken against you by an employer, professional or related organization, or a state licensing agency?
Yes
No
To your knowledge, are you presently under investigation by any of the above agencies or organizations?
Yes
No
Have you ever been found or pled guilty of a criminal charge (excluding traffic offenses) or liable in a civil action brought against you by any court?
Yes
No

In making this application for NDPA membership, I subscribe to and will support the objectives of the Association — “to advance psychology as a science, as a profession, and as a means of promoting human welfare” – and agree to abide by the ethical principles of NDPA. I hereby absolve NDPA, its officers and staff, Board of Trustees, Members, and Affiliates from damages or any other liabilities resulting from unfavorable action on my application or from disciplinary action or expulsion under the provisions of NDPA bylaws. The statements made in my application are true and complete. I authorize NDPA to contact my references and investigate my credentials. Unless I notify NDPA to the contrary, I authorize my name and address to be made available to outside individuals and organizations as part of NDPA’s mailing list.

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