I hereby apply for membership in the Iowa Psychological Association. I attest to the fact that I have not at any time been convicted of a felony, sanctioned by any professional ethics body, licensing board, or other regulatory body or scientific organization. I agree to advise the Executive Council of the Iowa Psychological Association by certified or registered mail at the time of IPA membership application or within thirty days of the occurrence, of any reportable events described in the above attestation of the Iowa Psychological Association membership application. I understand that directly reporting of disciplinary action by licensing boards, professional organizations or other authorities to same does not alleviate me from the responsibility of reporting disciplinary matters directly to the Executive Council of the Iowa Psychological Association.
In making this application, I subscribe to and will support the objectives of the Iowa Psychological Association and the American Psychological Association, as set forth in the Iowa Psychological Association’s Constitution and By-Laws and the American Psychological Association’s Bylaws, Ethical Principles of Psychologists and Code of Conduct.
I affirm that the statements made in this application correctly represent my qualifications for election, and understand that if they do not, my application may be voided. Copies of the above-cited documents will be made available to me upon request. I certify that the foregoing is true and correct under penalty of perjury under the laws of the State of Iowa.