Practice Licence Application – NIGERIA ASSOCIATION OF CLINICAL PSYCHOLOGISTS

Practice Licence Application Form

Nigerian Association of Clinical Psychologists (NACP)

Please complete this form carefully and accurately. All information provided will be used solely for the purpose of licence renewal verification.

Address: Date

1

Personal Information

Name

First

Last

(Surname first, in capital letters)

NACP Membership Number

Date of Birth

Gender

Male
Female

Telephone Number

Functional e-mail Address:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Country

Nationality

2

Professional Trainings / Workshop / Conferences

Current Employment

Internship Practice Experience

Sample Report written

Evidence of Completion

Drag & Drop Files, Choose Files to Upload

Professional Trainings / Workshop / Conferences attended in the last 12 months

1

Address Line 1

Address Line 2

City

State / Province / Region

1.Certificate upload

Drag & Drop Files, Choose Files to Upload

Please attach photocopies or scanned copies of certificates of recent trainings or workshop

2

Address Line 1

Address Line 2

City

State / Province / Region

2.Certificate upload

Drag & Drop Files, Choose Files to Upload

Please attach photocopies or scanned copies of certificates of recent trainings or workshop

3

Address Line 1

Address Line 2

City

State / Province / Region

3.Certificate upload

Drag & Drop Files, Choose Files to Upload

Please attach photocopies or scanned copies of certificates of recent trainings or workshop

4

Address Line 1

Address Line 2

City

State / Province / Region

4.Certificate upload

Drag & Drop Files, Choose Files to Upload

Please attach photocopies or scanned copies of certificates of recent trainings or workshop

5

Address Line 1

Address Line 2

City

State / Province / Region

5.Certificate upload

Drag & Drop Files, Choose Files to Upload

Please attach photocopies or scanned copies of certificates of recent trainings or workshop

Signature

Clear Signature

13. Renewal & Practice Licence Fees

S/N	Particular	Applicable Fee
1.	Annual Due	₦5,000.00
2.	Practice Licence Renewal Fee	₦10,000.00