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Copyright Restrictions

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TO: Candidates for election to office in Division 40

 According to the policies and procedures of Division 40, candidates for office in the Division are
required to sign the following statement.

Candidates, by virtue of accepting nomination to candidacy, agree that they shall advise the division secretary
by certified, registered or express and receipted mail, within thirty days of the occurrence of any of the
following events: (1) their psychology license in any jurisdiction is revoked, suspended, restricted, subject to
material conditions, or voluntarily relinquished or withdrawn; (2) a governmental body, a state, provincial or
territorial psychology board (or similar body responsible for supervising psychology practice), the American
Psychological Association, the Canadian Psychological Association or any affiliated regional, state,
provincial or territorial, county or other local psychological association determines that such psychologist has
committed professional misconduct or violated material rules of such body; (3) they have been convicted of a
serious crime, including any felony, any lesser crime an element of which under applicable law is fraud,
bribery, extortion, theft, or attempt or conspiracy to commit another serious crime and any other criminal act
involving moral turpitude; (4) if a court, a governmental body, a state, provincial or territorial psychology
board (or similar body responsible for supervising psychology practice), the American Psychological
Association, the Canadian Psychological Association or any affiliated regional, state, provincial or territorial,
county or other local psychological association determines that he/she is professionally incapacitated or
disabled by reason of mental or physical causes. This reporting obligation exists regardless of the pendency
of any appeal or other proceedings related to the triggering event, and regardless of whether any such
condition or sanction has already expired.

Reported matters must be submitted for review to the Election Committee, which may disallow candidacy or
recommend removal from office to the Executive Committee. Failure to report a matter as described above
can result in removal from candidacy or from office, if already elected.

     1. [ ] There have been no occurrences which are subject to the reporting requirements described above.

     2. [ ] All reportable matters are described in the attached information. I have (a) briefly described the
     matter, and (b) attached a copy of the final result or described its current status and attached key
     documents.

          I hereby attest that my response to the applicable preceding statement is true, complete and accurate
     to the best of my knowledge and belief.
 
 

 ______________________                            ___________
                              Signature                             Date
 

 ______________________
  Printed Name
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