PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES (PAP)

LICENSURE RENEWAL FORM

PERSONAL INFORMATION

NAME: DATE:

Contact Nos/Mobile: E-mail:

EDUCATIONAL ATTAINMENT

a) Undergraduate School You attained the Degree: Major:

AB_______________

BA_______________

BS _______________

b. Graduate School School You attained the Degree: Major:

MA _______________

c. Post-Graduate School School You attained the Degree: Major:

PhD _______________

CURRENT EMPLOYMENT
a. Job Title: c. Address: d. Contact #:

b. Employers Name: e. E-mail:

CHECK RENEWAL APPLIED FOR:

a. Psychometrician License No. : Expiration Date:
b. Psychologist

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 PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES (PAP)
LICENSURE RENEWAL FORM

CPD Point System: Total of 45 points

TRAINING AND EDUCATION

VENUE/SCHOOL Title Date Evidence CPD
(Original Certifi- Points
cate) Pls place
a check
Training Seminars/
Workshops

Conference
attended

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 PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES (PAP)
LICENSURE RENEWAL FORM

RESEARCH & PUBLICATIONS

Title Date Evidence: CPD

Copy of Points
publica-
Internation- tion(pls
place a
al/Local
check if
Publication/s submit-
(Book, peer re- ted)
viewed; Journal;
Chapters; journal
editor

Title of Conference and Paper and Venue Date Copy of CPD

Certifi- Points
cate (pls
place a
check if
submit-
Research Paper ted)
presentation
(Oral or Poster)

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 PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES (PAP)
LICENSURE RENEWAL FORM

Title of Conference and Paper and Venue Date Copy of CPD

Certifi- Points
cate (pls
place a
check if
Name Graduate submit-
School ted)
(*in a PAP ac-
credited school)

Title of Conference and Paper and Venue Date Evidence CPD

(pls place Points
a check if
submit-
Keynote/ ted)
Plenary Confer-
ence

INNOVATIONS IN PRACTICE

Title and Venue Date Evidence CPD

(please place a Points
check if sub-
Training/ Pro- mitted)
grams run in
Area of Spe-
cialization

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 PSYCHOLOGICAL ASSOCIATION OF THE PHILIPPINES (PAP)
LICENSURE RENEWAL FORM

Title, impact (international, na- Date & Evidence (Pls CPD

tional, etc), novelty (new, adapted, Duration place a check Points
etc) and Venue if submitted)
Implementation
of new inter-
vention

Title, type (test, book, etc) and Date Evidence (Pls CPD
contribution (author, editor, etc) place a check Points
if submitted)

Instructional
Materials
created

CONTRIBUTION TO PAP
Position Date Evidence CPD
Points

SUBMITTED BY: ______________________________________________

(PRINT NAME & SIGNATURE)

APPROVED: _______________ DISAPPROVED: ________________

DATE: _____________________

PAP BOARD EVALUATOR: __________________________________________

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