Get documents about "CPSP Directory Data Form 2010 revised fall
Document Sample
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:
Position/Title:
Address:
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
