Work Sample Fee - ABPA

Please check the box to confirm your agreement to the attestation statement below.

Attestation Statement

I actively maintain my practice of professional psychology in my specialty and hold valid statutory recognition in the jurisdiction(s) of my practice or

I no longer derive income from working as a psychologist (I may or may not retain a license). I am electing to maintain my ABPA Certification in Retired Status and

I have not received any professional misconduct or ethical violation judgments against me by the APA, CPA, or any affiliated state, provincial, or territorial psychological association that have not been previously disclosed to ABPA.

I agree that I shall advise the Executive Board within thirty days of the occurrence of the following events: my psychology license in any jurisdiction is revoked, suspended, restricted, subject to material conditions, or voluntarily relinquished; or a governmental body, the American Psychological Association, the Canadian Psychological Association or any affiliated state, provincial, or territorial association, determines that I have committed professional misconduct, or violated material rules of such body. This reporting obligation exists regardless of the pending outcome of any appeal or other proceedings related to the triggering event.

We want to advise you that if the matter you report is relatively minor and/or unsubstantiated, ABPA will simply note your cooperation in the reporting process. However, if that matter is major and substantiated, it will be reviewed by the Executive Board of ABPA.