Upgrade to Professional Member If you are already an Associate Member of the PSA you can use this form to upgrade to Professional Member. Title*MrMsMissMrsDrRevName* First name Last name 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 GrenadinesSaint MartinSamoaSan 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 TelephoneMobile Telephone*Email* 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 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 Ethics*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 upgradingOtherReferrer's nameHave you been introduced to the Association by another member? If so please provide their name below so we can thank them. (One name only please). First name Last name Annual Subscription - Professional MemberThis payment is for an annual subscription as Professional Member. You will be charged £225 per year.Annual Subscription - Professional MemberCredit Card American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name I do not wish to receive information from the PSA after my membership has come to an end. When I submit this form, I understand that the PSA will process my information in accordance with its Privacy Notice.EmailThis field is for validation purposes and should be left unchanged.