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Resume Membership Application Form - The Psychological Society of by huangyuerongp4


									THE PSYCHOLOGICAL SOCIETY OF IRELAND Cumann Síceolaithe Éireann
CX House, 2A Corn Exchange Place, Poolbeg Street, Dublin 2. Tel: 01 - 4749160 Fax: 01 - 4749161 Email:

This form must be completed by individuals who have been Members of PSI but whose membership has lapsed.

Surname _______________________________

Name(s) __________________________________

Address (to which all correspondence should be sent): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Telephone ______________________________ Email ____________________________________

PSI Membership Number (if known)


I enclose the Resume Membership Application fee of €50 and the appropriate membership fee of € __________. Total fee enclosed € __________. For your convenience, the schedule of fees for the current year is included overleaf. Yes__ No__ No___ No___ No___

Have you ever been refused membership of a psychological society? If yes, please enclose details.

Have you been the subject of disciplinary proceedings by any professional body? Yes___ If yes, please enclose details. Have you ever been convicted of a criminal offence? If yes, please enclose details. Do you know of any reason why you should not be granted membership? If yes, please enclose details. Yes___ Yes___

I understand that any complaint under the Code of Professional Ethics made against me during my period of lapsed membership may be investigated by the Society. I declare that, to the best of my knowledge and belief, the foregoing statements are true. Signed ________________________________________ Date _________________________

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