NAME: ______________________________________  SEX:_________________
	Last	   First	    Middle
PRESENT POSITION:_________________________  CIVIL STATUS:_____________
INST'L. AFFILIATION:___________________  PHONE:_______________________
ADDRESS:______________________________ ZIP CODE:______________________
________________________________________ FAX NO:______________________
HOME ADDRESS:_________________________ZIP CODE:_______________________
_________________E-MAIL:_________________PHONE:_______________________


RESEARCH AND PUBLICATIONS
	TITLE		       DATE
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

YEARS OF EXPERIENCE IN THE FOLLOWING AREAS:

( )Teaching		(  ) Research		(  ) Supervision
( )School Counseling	(  ) Private Practice

AREAS OF INTEREST IN COUNSELING PSYCHOLOGY

(  ) C'ling Theory & Techniques		(  ) Career C'ling		
(  ) Research				(  ) C'ling Supervision
(  ) C'ling Special Groups		(  ) Peer C'ling
(  ) Others


	I hereby certify that the above information is accurate 
and complete to the best of my knowledge. I attach herewith my 
transcript of records, as required, and a 1x1 ID photo.


Signed : ______________________________
Date : ________________________________


Nominator: ______________________________
Affiliation :____________________________


ACTION OF MEMBERSHIP COMMITTEE

(  ) Approved		(  ) Deferred		(  ) Disapproved
Classified as:		(  ) Regular		(  ) Associate	
(  ) Affiliate
Comments : ______________________________________________________
Date : _________________________

*MEMBERSHIP WILL TAKE EFFECT UPON RECEIPT OF MEMBERSHIP FEE
RECORD OF PAYMENT

Date Received: __________Amount:___________________
Mode of Payment:	(  ) Cash	(  ) Cheque

Attested by: _____________________________________
			CORPORATE SECRETARY
			Date: ____________________