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Title*MrMsMissMrsDrRevName* First Last Company or organisationAddress* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone*Mobile TelephoneEmail* WebsitePlease include http://Which Regions would you like to attend?*Select at least one. However you can select as many as you like. East of England London Midlands North East North West South East South West Staffordshire Thames Valley Yorkshire Wales Scotland Ireland Why do you want to make this application?List your 10 most recent speaking events*Please list your TEN most recent speaking events for audiences of 3 or more people. (Click the + sign to add a new row.)DateEventAudience Size I earn money from speaking* Yes No Name of First Proposer*The name of your proposer. You require TWO proposers who can be either Professional Members or Fellows. Associate Members cannot propose you for this grade of membership.Second Proposer's Name*The name of your proposer. You require TWO proposers who can be either Professional Members or Fellows. Associate Members cannot propose you for this grade of membership.Date You Were Seen Speaking*Please enter the date on which one of your proposers saw you speak. You must have been seen speaking within the last 12 months. Link to Video of You SpeakingPlease provide a link to a video of you speaking, either on YouTube or another online video service or your own website. Proposers Agreement* Tick to confirm your proposers have agreed to support your application Speaking Topic*Choose the overall speaking subject area.Choose One Main Topic >>AccountancyAfter DinnerArtsBusinessCoachingCustomer ServiceEconomicsEducationEngineeringEnvironmentEqualityExploringFamilyFinanceFutureGenderHealthHuman ResourcesHumourInformation TechnologyInternational AffairsInternetLeadershipManagementMarketingMediaMotivationPersonal DevelopmentPoliticsPresentation SkillsPsychologyPublic RelationsSalesScienceSocietySportTeamworkTrainingTravelOtherSpecific Speaking TopicsPlease list specific things you talk about - one per line.Other TopicsYou may choose more than one by holding down the CTRL key as you select.After DinnerArts/CultureAthletics/SportsBusinessEducationEnvironmentEqualityFamilyFuture TrendsGender IssuesGovernment/PoliticalHealthHumourInformation TechnologyInternational AffairsInternetLeadershipMediaMotivationPersonal DevelopmentPresentation SkillsPsychologySalesScience/EngineeringTravel/ExplorationOtherEthics*You are required to agree to the ethical code of conduct of the PSA.This can be found at: http://www.thepsa.co.uk/membership/ethics/ Tick to confirm you agree with the ethical principles of the PSA How did you hear about the PSA?*A friend recommended the PSA to meThe WebsiteAttended a Regional MeetingAlready in membership - just upgradingOtherBy Completing this form you agree that the PSA can email you* I Agree Annual Subscription - Professional MemberThis payment is for an annual subscription as Professional Member. You will be charged £225 per year.Annual Subscription - Professional MemberThis page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.