Hold Harmless / Ethics Attestation
In making this application, I agree to be bound by the Ethical Principles of Psychologists and
the Code of Conduct of the American Psychological Association. I affirm that the statements made
in this application correctly represent my qualifications for membership and understand that if
they do not, my membership may be voided. I understand that my membership in IPA does not certify
my competence in any area of psychology. I will not use my membership in IPA as an indication of
my competence in any representation to the public.
Membership may be denied to an applicant for cause, which includes but is not limited to disciplinary
action for ethical reasons by the American Psychological Association, disciplinary action by any
Psychology Licensing Board (including but not limit to censure, suspension, revocation or denial of
licensure), misrepresentation of qualifications to the public or the Association, or any cause that
constitutes grounds for disciplinary action by the Illinois Clinical Psychologists' Licensing and Disciplinary Board.
Automatic Membership Renewal
Your membership will be automatically renewed each year unless you choose to opt out by selecting "No" below.
Step 2: Section Membership - Optional
$12.50 (included with Grad Student Membership)
Step 3a: Mandatory Base $30 Legislative Assessment Fee for Licensed Members Only
Step 3b: Mandatory Supplemental Legislative Assessment Fee for Licensed Members Only
If your annual net income is:
$30,000 - $50,000 : $40
$50,001 - $80,000 : $65
$80,001 - $110,000 : $85
Over $110,000 : $100
Explanation of the Licensed Psychologist Legislative Assessment Fee: The base Legislative Assessment is $30 for all licensed psychologist. The
Mandatory Supplemental Legislative Assessment is based on your income. These assessments are designated exclusively for IPA Legislative and Advocacy
activities. The IPA continually defends the rights of psychologists to continue to provide the services for which they are trained. The IPA also
monitors activities and advocates for legislation that has an impact on the consumers we serve, consumers who are not organized to protect
themselves. A legislative assessment is charged to all psychologists with the rationale that even those psychologists who see only a few patients a
week do so because the IPA works to protect that right.
Step 4: Total:
Credit Card Information