peica

Application for Membership

Membership in PEICA runs from January 1 to December 31 of any calendar year.

PERSONAL INFORMATION

Name:

Address:

Postal Code:

Phone:

(work)                   (home)                        Fax:

(work)                    (home)

E-mail:

PROFESSIONAL QUALIFICATIONS

Highest Degree:

University:


Year of Graduation:

Area of Specialization:

Work Setting:

PEICA Membership Category:
Full/Associate $30
or
Student/Retired $20

I wish to be a member of the following Chapter(s):

_____PEITF-SCC - School Counsellors= Chapter

_____CPC -Counselling Psychotherapist Chapter (Those interested in pursuing CCC must join through CCPA after February 21/07.)

DECLARATION

1. I confirm that I do not have a criminal record that might prejudice my work as a counsellor.

OR

     I attach details of conviction(s) to be taken into account in considering this application for membership.

2. I confirm that I have not been dismissed from employment or refused membership in a professional association or                registration in counselling or a related field, on the grounds of professional misconduct in Canada or elsewhere.

OR

    I attach details of matters or sanctions to be taken into account in considering my membership application.

3. As a member of the Prince Edward Island Counselling Association I do hereby pledge to uphold the CCPA Code of Ethics at all times.

4. To benefit from any grant PEICA may offer its members, one must be a member at least 30 days prior to an event(s) early bird registration or, in the absence of an early bird registration, 30 days before the regular registration date.

Signature:                                                                 Date:

CHEQUE PAYABLE TO:

PEI Counselling Association,

Mail To:

Maribeth Noonan,
Box 4504, RR#3
Summerside, PE
C1N 4J9