|
Membership
Application |
| Application
Information |
New
Renewal |
Name
|
|
|
Title |
|
Please
send completed application with supporting documents and payment
to: |
Address |
|
City
|
|
CWP
PO Box 1583
Claremont, CA 91711
Make checks payable to CWP. |
State |
|
Zip |
|
Email |
|
Tel(day) |
|
Tel(evening) |
|
Mobile |
|
Best
time of day to reach you |
|
|
| |
| Select
a Membership Level |
Professional Level...................annual dues $100
Please provide documentation for each:
Photocopy of current license, as required by your discipline.
Proof of current Professional liability insurance coverage
(front page only). |
Associate Level......................annual dues $20
Please provide proof of current enrollment as student. |
|
Friend of CWP.......................any donation welcome |
| |
|
Membership
Agreement |
| I
have/
have not had a permit or license related to my professional practice
revoked or suspended. (If yes, please explain) |
| I
am/
am not currently under and disciplinary action on a complaint in
this state or any other location. (If yes, please explain) |
|
I agree that the information I have provided is true. |
| |
Professionals: Would you like to be listed on our
website? Please use format below!
|
|
CWP
Professional Level Members: Bio Format |
| Practice
and Philosophy |
| License
and Certification* |
I am certified as,
, and I am licensed as
*We
require copies of your license and certification as
part of the application, together with dues.
|
Practice
Description
|
Philosophy
|
Educational
Background |
Formal
Education: List with highest degree first (most recent); include
only post-secondary education.
|
Specialized
Education: List non degree courses, continuing education or workshops(dates/years
optional)
|
|
Professional
Associations |
| List
memberships in professional organizations (list CWP last with year
started; alphabetize all others) |
|
|
Honors/Awards |
| List
only if applicable; if none, category not listed on web page. |
|
|
Speaking
Topics |
| List
only if applicable; if none, category not listed on web page.. |
|
|
NOTE: CWP reserves the right to edit submissions for length
and clarity. Personal data is listed, not advertisements for the
individual's employer; self-employed individuals may promote their
own business. |
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| |