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APS COLLEGE OF CLINICAL PSYCHOLOGY

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					APS COLLEGE SUPERVISOR’S DIRECTORY

REGISTRATION                 AND APPLICATION                  FORM



We are committed to protecting your privacy
 1. We are committed to protecting your privacy, and the confidentiality and security of the        c) if you are a Member, Fellow or Honorary Fellow of the APS, your name, Preferred
    personal information you provide.                                                                   Telephone Contact number and the Organisation for which you work (as advised on
 2. The personal information provided by you on this form will be used to:                              page 2 of your Annual Subscription Notice), as well as the State in which you are
   • Process your application and update your personal details and membership profile                   located and your membership of APS Colleges and Divisions will appear (unless
      information.                                                                                      otherwise directed by you) in the Directory of Members available on the APS
   • Provide members with access to and information about a range of current and future                 Website. Your other details, including address information, will remain
      benefits.                                                                                         confidential. If you do not wish to be included in the Directory of Members, or you
   • Identify your Preferred Telephone Contact number, which may be disclosed to the public             wish to be included but do not want your Preferred Telephone Contact number and /
      and other members, and other details included within the Membership Directory (refer              or the Organisation for which you work listed, please write in confidence to the
      point 3 below for further details).                                                               Director of Membership.
   • Provide the APS with statistics related to its membership.                                  4. You have the right to access personal information held by the APS that relates to you,
3.     The personal information you have provided on this form may be disclosed to persons          subject to the exceptions in the Privacy Act 1988, and to correct such information which
       and organisations as follows:                                                                is incorrect. Please contact the APS National Office with any such request.
   a) organisations external to the APS that provide us with administrative assistance in the    5. For more information on the Society’s policies regarding privacy, refer to the APS
      delivery of some of the services you receive.                                                 Website at www.psychology.org.au Copies of the full APS Privacy Policy may be
   b) the APS may release your Preferred Telephone Contact number in response to a request          obtained from the APS National Office on request.
      from the public or another member. If you do not want this telephone number released,
      please write in confidence to the Director of Membership.                                                                                                       ABN 23 000 543 788




PLEASE INDICATE THE COLLEGES FOR WHICH YOU ARE ELIGIBLE TO SUPERVISE

     Clinical                 Clinical Neuro                  Community                         Counselling                  Educational & Developmental
    Forensic                  Health                          Organisational                    Sport



                                                                            APPLICANT DETAILS

Prof.              Assoc. Prof.                      Dr             Mr              Mrs          Ms              Miss
                                                                                                                                         FORMER NAME, IF APPLICABLE
Family Name
Given Names                                                                                                                                 Date of Birth                   /       /
Telephone                       (W)                                                                              (H)
Mobile                                                                                                      Please circle preferred contact:               Work       Home       Mobile

Suburb                                                                                                                 State                         Postcode

APS Membership No.                                                        Membership Grade                                               Date Elected                       /       /



                          Supervisors must have held Full College Membership for 2 years.


        Please list my name and telephone contact information as provided above in the College’s Directory of
        Supervisors to be placed on the APS website. This will also be available for distribution at the discretion of the
        Membership Secretary, APS Colleges or APS National Office Staff.



Signature                                                                                                                                            Date               /          /



                         Note: If the preferred contact is not circled, it will default to the work contact number.


Once you have completed this form, please return it to:
                                               The Australian Psychological Society Ltd
                                                 APS College Supervisor’s Directory
                                PO Box 38, Flinders Lane PO, MELBOURNE VIC 8009, AUSTRALIA
                            Telephone: (03) 8662 3300 or 1800 333 497 (toll free) Facsimile: (03) 9663 6177

				
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Description: APS COLLEGE OF CLINICAL PSYCHOLOGY