MEMBERSHIP APPLICATION FORM
 
Personal Data
1.
__________________________________________________________________
Surname
Given Name
2. Email Address: _____________________________________________________
3. Mailing Address Label:
Name:______________________________________________________________
Address:____________________________________________________________
City/Province:________________________________________________________
Postal
Code:_________________________________________________________
Telephone Number:
Home:_________________Business:_____________________
4. Name and Address of Employer:
Name:______________________________________________________________
Address:____________________________________________________________
City/Province:________________________________________________________
Postal
Code:_________________________________________________________
Membership Category Sought
Please check only one category of membership (Refer to
Membership Information).
_______ 1. Full member
2. Affiliate member
_______ i) allied profession or not meeting full membership
requirements
_______ ii) residing outside of Manitoba
_______ 3. Student member
Membership Requirements
Check only one of the requirement options under which you are
applying. (Refer to Membership Information). These options apply to all
membership categories.
Option
Instructions
I_________
Forward official University transcripts and/or letter of
employment verification.
II________ Photocopied Clinician's
Certificate attached.
III_______ Photocopied Letter of
Eligibility attached.
Declaration
I hereby certify that the information provided and attached
herewith is true in all respects.
Signature:____________________________
Date:________________________________
Forward application, applicable attachments, and fee (payable
to Manitoba Association of School Psychologists)
to the following
address:
Membership Chair
Manitoba
Association of School Psychologists
162
- 2025 Corydon Avenue, Suite
562
Winnipeg,
MB R3P 0N5
Canada
For MASP Membership Committee Use Only:
Date Reviewed:_______________Complete:__________Incomplete:______________
Date
Accepted:________________ Chairperson's
Initials:___________
Receipt and Certificate Issued:_____________
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