Membership Application

Emeritus Membership

Emeritus memberships require approval. Upon submission of the form below, your information will be reviewed and if approved, you will be provided with payment instructions.

Prefix

First Name *

Middle Name

Last Name *

Suffix

Address

Street Address *

City *

State or Province *

Country *

Postal code *

Primary Email *

Alternate Email

Practice Group(s)

Primary Practice Group

Additional Practice Groups

Main Office Details

This is the address that will be included in the PUBLIC directory if you choose to be listed.
You must include the State/Province and Country fields if you wish to be included when directory users filter by those parameters.

Office Street Address

Office City

Office State

Office Postal Code

Office Country

Office Email

Office Phone

Sharing Preferences

Display in Public Directory *

Yes

Data Sharing *

Yes

IACP occasionally makes its members' addresses (excluding telephone and email) available to other colleague organizations and to vendors who provide products and services to the Collaborative community. If you prefer not to be included in these lists, please select 'no'.

Professional Information

Area(s) of Practice *

License(s) *

Website Link

Facebook Link

LinkedIn Link

Education Information

Please enter information in the following format: Name of Institution, 4-digit-year

Example: Loyola Marymount, 1991

Undergraduate Education

Postgraduate Education

Professional Education

Additional Details

Introduction / Very Brief Bio

Accommodations

Proficient in LGBT matters

Disabled-accessible office

Multilingual

ASL

Who Referred You to IACP?

Is there anything else that you need us to know about your application?