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INDIAN ASSOCIATION OF CLINICAL PSYCHOLOGISTS

(REGISTERED IN 1968 AS PER SOCIETIES REGISTRATION ACT XXI OF 1860 REG . NO. 3694)

APPLICATION FORM FOR MEMBERSHIP

Class of Membership: (Fellow, Professional, Associate)

Name and Address:..

Age

Gender

Residential Address (Block Letters)

....

...
..Pin..
Email ID
Mobile No

Landline no

Designation of the present post and official address

...
....
..Pin
Degree/Diploma

Subject

Institution

Year
(Passing)

Graduation
Post Graduation
D.M& S.P/M.Phil.,
M.& S. / C.P.
Ph.D
Any other
Particulars of professional experience (Specify: Practice / Teaching / Research in the field of Clinical
Psychology)

DESIGNATION

PLACE OF WORK

FROM

TO

* Please send all relevant certificates /documents as scanned soft copy by e mail
and self-attested hard copy by regular mail, along with your application. After
provisional acceptance of the application, applicant will be advised to make the
payment after which the applicant will be elected.

Other jobs or position held:

Particular of other professional affiliation:
1. Professional membership: M.Phil. Clinical Psychology or M.Phil. Medical and social Psychology or M.Phil. Mental Health and
Social Psychology or the former post Graduation Diploma Course that is Diploma in medical and Social Psychology / Diploma in
Medical Psychology of National Institute of Mental Health and Neuro Sciences, Bangaluru or Central Institute of Psychiatry, Ranchi
or any other Institution with the prescribed equivalent course for M.Phil or Doctorate in clinical Psychology with a prescribed
residential course and research as on the pattern of NIMHANS, Bengaluru.
2. Fellowship:
i. Professionals life membership of the Association for a minimum period of two years.
ii.Ten Years of Experience in the field.
3. Associate Membership: Graduation in psychology/ Law/ Medicines/ Psychiatry or Post Graduation degree in any other Social
sciences or Humanities or Psychiatry

Membership Fees.
Fellowship fee
Professional members (Annual subscription)
Associate members (Annual subscription)
Life members (Professionals)
Life members (Associate)

Rs. 2000/Rs. 600/Rs. 600/Rs.5000/Rs.4000/-

I, _____________________________________________________________
Certify that the particulars given above are true to the best of my knowledge.
I am interested in the aims and objectives of IACP and undertake to abide by the rules and
regulations during the tenure of my membership.
I am attaching the copies of my professional degree certificates to substantiate the qualification
required for the membership category applied for.
Preferred mailing address (Write in capital
Letters)-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Email
---------------------------------------------State-----------------------------Pin Code------------------------Place :
Date :

Signature of Applicant

The application form should be sent to The Hon. Secretary, IACP at the address given below.
Dr.Kalpana Srivastava, Hon. Gen. Secretary, IACP
Scientist F, Department of Psychiatry
Golden Jubilee Block
Armed Forces Medical College ,Pune
Maharashtra, Pin 411040
Email : iacpsecretary@gmail.com
FOR OFFICE USE ONLY
Received Rs. ------------------------------- which includes membership fees/life membership
installment or full in the mode given above -------------------------- as per article
------------------------------------------------------ of IACP memorandum under the approval of Executive
Council meeting held on -------------------------------------------------------------------.
Place

Date:

Signature
(Secretary IACP)

Remarks Admitted/Not admitted

Class of Membership