CPSP Directory Data Form 2010 revised fall by MxF2b1


									             P.O. Box 3647, Wantagh, NY 11796 | (212) 246-6410 | www.cpsp.org

                                                                                Directory Data Form 2010
The information that you provide on this form will be used for the CPSP Directory, as well as verifying your certification, and recording your annual
dues. Any questions about this form should be directed to the CPSP Registrar, Barbara McGuire, at cpspregistrar@gmail.com. Questions about CPSP
dues and fees should be directed to: Charles Kirby, CPSP Treasurer, P.O. Box 6551, Hendersonville, NC 28793-6551, or by email at
cpsptreasurer@gmail.com. Thank you for your cooperation.                   Created 12/16/05, Last Revised 10/13/10
Today’s Date:                   NOTE: The information that you submit on this form will be published in the Directory on www.cpsp.org and
                                possibly in print. Do not include information that you would not want to be discoverable.
Please check the appropriate box(es):                                                      My certification has changed.
   I am a New Member of CPSP.                                                              My information has NOT changed – I am submitting dues/fees.
   My personal information has changed (Directory update).                                 Dues have been sent to Treasurer.
                                                                         PERSONAL CONTACT INFORMATION
Title:                                   First Name:                                                               Last Name:

Primary Address/PO Box:

City:                                                                                              State/Province/Territory/Region:         ZIP/Postal Code/Routing:

COUNTRY:                                                             Telephone:                                               Fax Number:

Web/Email Address:                                                                                 Mobile Phone Number:

Religious Affiliation:                                                                                                                      Ordained:
                                                                                                                                               Yes          No
                                                                     PROFESSIONAL CONTACT INFORMATION
Institution’s, Organization’s, or Company’s Name:



City:                                                                                              State/Province/Territory/Region:         ZIP/Postal Code/Routing:

COUNTRY:                                                             Telephone:                                               Fax Number:

                                                                CPSP INFORMATION
Please check your current certification that you have a certificate(s) for at this time. If you have not received a certificate and have paid your dues,
please check ‘member’.
        Member                                                            Clinical Chaplain                                     Diplomate Supervisor
        Associate Clinical Chaplain                                       Pastoral Counselor                                    Diplomate Psychotherapist
        Associate Pastoral Counselor                                      Clinically Trained Minister                           In Training

                                                                    CPSP CHAPTER
         Please check your current chapter. If you do not see your chapter name listed here, please check ‘other’ and type the name of your chapter.

   Arecibo, Puerto Rico                                  Fayetteville, AR                               Miami, FL*                             Schenectady, NY
   Atlanta, GA                                           Flint Hills, TX                                Missouri River Valley, MO              Seattle-Tacoma, WA
   Auburn, AL*                                           Fort Bragg, NC*                                Napa Valley, CA*                       South Bay, CA*
   Baltimore, MD                                         Four Corners Sages Way, CO                     Nassau, NY                             Stoney Mountain/Asheville, NC
   Bentonville, AR                                       Garden City, NY                                Neuse River, NC                        Suffolk County, NY
   Berkeley/Bay, CA*                                     Glenwood Springs, CO                           New Amsterdam, NY*                     Tri-State – NY
   Brooklyn, NY                                          Goldsboro, NC                                  New England, MA                        Tuscon, AZ*
   Centerville, OH                                       Grand Junction, CO                             New York/New Jersey                    Tulsa, OK*
   Central Ohio                                          Greensboro/Winston-Salem, NC                   Newark, NJ                             University Park, CO
   Central Oklahoma                                      Hammock Lake, OH                               Northern Colorado*                     Wasatch, UT
   Chapel Hill, NC                                       Hampton Roads, VA                              Ohio Valley, OH                        Washington D.C., MD
   Charlotte, NC                                         Hampton/Newport News, VA                       Opelika, AL*                           Washington Heights, NY
   Chesapeake, MD                                        Harrisburg, PA                                 Orlando, FL                            Western Europe
   Cincinnati, OH                                        Hong Kong, CHINA                               Pacific, CA                            Wilmington, DE*
   Columbia, SC                                          Kansas City, KS*                               Philadelphia, PA                       OTHER:
   Corpus Christi, TX                                    Kettering, OH                                  Piedmont-Triad, NC
   Cottonwood, UT*                                       Laconia, NH*                                   Pikes Peak, CO                      * Chapter in Formation
   Dallas-Fort Worth, TX*                                Lake Belton, TX                                Pinehurst, NC*
   Dayton, OH                                            Laredo (La Frontera), TX                       Pittsburgh, PA
   Deep South, MS                                        Laredo, TX                                     Princeton, NJ*
   Denver Metropolitian, CO                              Las Palmas, TX*                                Port Credit, CANADA
   Denver South Platte River, CO                         Lexington, KY                                  Rio Grande Valley, TX*
   Denver, CO                                            Little Rock, AR                                Rocky Mountain, CO
   Denver Sloan’s Lake, CO                               Los Angeles, CA*                               Salisbury, MD
   Denver University Park, CO                            Manhattan, NY                                  Salt Lake City, UT
   Edison, NJ                                            Maryland Eastern Shore, MD                     San Antonio Central, TX
   Far Rockaway, NY                                      McAllen, TX                                    San Antonio, TX

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