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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