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Membership Renewal Application.

Fields marked with a '*' are mandatory
Click Here for a PDF file about Supervision Requirements.

Your name: *

 
Address: *Telephone: *
Email: *

Please give details of any specialities:
Fluent in any languages other than English:
Are you applying for upgrade of membership?
Yes No (if 'No' go to Session Numbers)
If 'Yes', to which grade?
Existing Membership grade:
When did you qualify?

Session Numbers
How many sessions monthly * Teachers only - how many teaching hours monthly?
Supervisor's details (or go to 'Declaration' if not in practice)
Type of Supervision: Differential Peer
When started:
Session frequency and length:
Main modality: Face to Face Telephone Other (please specify):
Please note: Supervision details are subject to a random checking procedure

DECLARATION (This is subject to randomised checks)

Check all appropriate boxes:
I want to renew my membership of both NRPC and APHP at £105.00.
I have not been in practice during the last 12 months and do not expect to be so in the coming year.
I have not been in practice during the last 12 months but expect to commence during the coming year.
I have professional indemnity insurance; my certificate number is:
I know of no legal or other reasons why my membership should not be renewed.
I have attended a minimum 15 hours CPD training in the last twelve months, as follows:

Please Note: CPD details are subject to a random checking procedure

I'll pay my subscription by:
 
Card Type:
Card number (This is a secure form):
Start date (mmyy):
Exp. date (mmyy):
Issue number:
Security number (last 3 digits on back of card - 000 if not paying by card): *

Application Date: *
              Signed: * This typed signature signifies that you confirm all details on this form are correct to the best of your knowledge. Where this name does not match that at the top of the form, the application will not be processed.

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