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What is your date of birth
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Ethnic Origin
If you are of Maori descent, please supply details of your Iwi and Rohe
What languages, other than English, so you use professionally with clients?
Please indicate which areas you work in (required) Child & FamilyDHBForensicCorrectionsACCIntellectual DisabilityUniversityPrivate PracticeAlcohol & DrugPHONGONeuropsychology
Which NZCCP Branch would you belong to? AucklandHamilton/TaurangaHawkes BayPalmerston NorthWellingtonNelsonChristchurchOtago/Southland
If you want your details published as being available to accept client referrals please complete the following
Business Name
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Business Email
Please list two specialist areas
I am registered as a clinical psychologist with the NZ Psychologists Board (required) ---TrueFalse
In the past 12 months I have not had a complaint laid against me with the Psychologists Board, or equivalent overseas body, the Health and Disability Commissioners, or part of the judicial system, in relation to my professional conduct (required) ---TrueFalse
If there is such a complaint I agree to provide to the President or his/her nominee of the College brief details and give permission for the release of any records pertaining to complaints made to, or actions taken by, the above authorities (required) ---YesNo
I wish to renew my MPS membership (required) ---YesNo
I agree to be bound by the Memorandum of Articles and Association currently in force with MPS ---TrueFalse
I understand that if my subscription is in arrears for more than one month then I shall cease to be entitled to any membership benefits from MPS from the date when such subscription fell due ---TrueFalse
I also understand that after non-payment of three months then MPS may terminate my membership by notice ---TrueFalse
When you click submit, you will be sent an email with a link to the payment page where you can pay online by credit card. If you wish to pay by cheque, or direct electronic transfer, simply close that window and Post your cheque to: Caroline Greig, NZCCP, PO Box 24 088, Wellington OR Make a direct credit to: NZCCP BNZ account 02-0865-0271109-00 Please identify yourself clearly when making the payment via your bank