THE PHILIPPINE GUIDANCE AND COUNSELING ASSOCIATION

,
INC
MEMBERSHIP APPLICATION FORM
PGCA Membership Committee
NAME______________________________________________________
(Please Print) Last
First
Middle

Civil Statatus:
Sex:

__________
__________

Present Position/ Title:________________________________________
Institutional Affiliation:_________________________________________
_______________________________________

Phone: _______________
Fax No. _______________

Address: ____________________________________________________
____________________________________________________

Zip Code:______________
E-mail: ______________
______________________

Home: ____________________________________________________
Address: ____________________________________________________

Zip Code: _____________
Phone No: ____________

Highest Educational Degree: ______________________________________________________________
MAJOR:
1. ________________________________
2. ________________________________
Obtained From: (School/ Institution)
1. ________________________________
2. ________________________________

(Note: If on-going, indicate no. units
earned to date) ___________
Year:____________
Year:____________

Related Non-Degree Training: (not less
than 3 months)
Year Started in Guidance Work: ____________

1. __________________
2. __________________

School: _______________________
Address: ______________________

Areas of Concentration:
____ school counseling
____ human relations training
____ clinical counseling
____ marital and family counseling
____ industrial counseling
____ counseling adolescents

______ research
______ career counseling
______ test development/ construction
______ counseling special groups e.g. learning disabled
______ autistic, gifted, hyperactive(ADD),dyslexic,addictive
______ Others, Please specify

Please Check:
_____ New Applicant

_____ Updating Membership

First Applied on: ________

I hereby certify the above Information is accurate and complete to the best of my knowledge. I
enclose herewith a photograph and my transcript of records.
____________________________
Signature
----------------------------------------------------------------------------------------------------------------------------------------------------ACTION OF MEMBERSHIP COMMITTEE
ACCEPTED AS ACTIVE MEMBER:
For: CY 2006-2007
Status:
_____ Regular
_____ Associate
FEE: Amount P _________
O.R. # _________
Date:
_________
Form of Payment:
______ Check
______ Cash
______ PMO

DATE OF APPROVAL ___________
Action taken:
Sent Acceptance Letter On _________
Entered Name In Directory _________
Sent ID and Receipt
_________
(membership payment)
_________________________________
Chairman, Membership Committee
_________________________________
President/ PGCA

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