Membership Application Form

NIGERIAN ASSOCIATION OF CLINICAL PSYCHOLOGISTS (NACP)

Please complete the form. It will be used for your membership registration.

Your Current Session Information

IP Address: Loading…

Location: Loading…

Network Provider: Loading…

Date:

Time:

Device Used:

1

Personal Information

Full Name of Applicant

First

Last

(Surname first, in capital letters)

Date of Birth:

Gender

Male
Female

Address : State where you are currently employed or practicing

Address Line 1

City

State / Province / Region

Country

State where you are currently employed or practicing

Telephone Number

Functional e-mail Address

Nationality

Upload passport

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera

Affix your recent colour passport size photograph

2

Post-Secondary Educational/Professional Qualifications

Membership Applied for

1.Educational Background BSC

Address Line 1

City

State / Province / Region

Country

Area of Specialization

Upload B.Sc Certificate

Drag & Drop Files, Choose Files to Upload

2. Educational Background MSC

Address Line 1

City

State / Province / Region

Country

MSC is Required for Full member Application

Area of Specialization

Upload M.Sc Certificate

Drag & Drop Files, Choose Files to Upload

Upload Transcript

Drag & Drop Files, Choose Files to Upload

3. Other Educational Background

Address Line 1

Address Line 2

City

State / Province / Region

Country

Optional

of

Upload Certificate

Drag & Drop Files, Choose Files to Upload

Optional

4.Other Educational Background

Address Line 1

Address Line 2

City

State / Province / Region

Country

Optional

Upload Certificate

Drag & Drop Files, Choose Files to Upload

Optional

5. Other Educational Background

Address Line 1

Address Line 2

City

State / Province / Region

Country

Optional

Upload Certificate

Drag & Drop Files, Choose Files to Upload

Optional

3

Professional Trainings / Workshop / Certifications/ Conferences attended

1.Training and Workshops

Address Line 1

Address Line 2

City

State / Province / Region

2.Training and Workshops

Address Line 1

Address Line 2

City

State / Province / Region

3.Training and Workshops

Address Line 1

Address Line 2

City

State / Province / Region

Optional

4.Training and Workshops

Address Line 1

Address Line 2

City

State / Province / Region

Optional

5.Training and Workshops

Address Line 1

Address Line 2

City

State / Province / Region

Optional

4

Please upload your Curriculum Vitae (CV) and scanned copies of all academic and professional certificates.

1. CV Upload

Drag & Drop Files, Choose Files to Upload

2. Supporting Documents

Drag & Drop Files, Choose Files to Upload

Optional

3. Supporting Documents

Drag & Drop Files, Choose Files to Upload

Optional

4. Supporting Documents

Drag & Drop Files, Choose Files to Upload

Optional

5

Brief Professional/Work-related Experience (start from your current employment)

1. Professional/Work-related Experience

Address Line 1

Address Line 2

City

State / Province / Region

Country

2.Professional/Work-related Experience

Address Line 1

Address Line 2

City

State / Province / Region

Country

References (2 Full members of NACP)

6

References (2 Full members of NACP)

Please provide names and other details of two referees who must be full, up-to-date members of NACP. Oversees-trained Applicants who do not know any qualified full member to sponsor themshouldapproachthe State Chairman of their intended state of operation or the President to sponsor them.

1. Reference

Address Line 1

Address Line 2

City

State / Province / Region

Contact number

Email

Signature

Clear Signature

References (2 Full members of NACP) 1 of 2

2. Reference

Address Line 1

Address Line 2

City

State / Province / Region

Contact number

Email

Signature

Clear Signature

References (2 Full members of NACP) 2 of 2

3. Other Reference

Address Line 1

City

State / Province / Region

Contact number

Signature

Clear Signature

7. Category of Membership Applied For

S/N	Membership Category	Applicable Fee
1.	Full Member	₦50,000.00
2.	Student Member (Compulsory for all current MSc. Clinical Psychology students)	₦10,000.00
3.	Membership Upgrade (from Student Member to Full Member)	₦25,000.00
4.	Affiliate Member	₦25,000.00

8

Recommendation by the State Chairman

State Chairman Name

First

Last

Date

Practicing State

State Chairman Signature

Clear Signature

State chairman Comment

9

Applicant Confirmation

Signature of Applicant

Clear Signature