User account

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Password: *

Confirm password: *

Provide a password for the new account in both fields.

Personal Information

First Name: *

Last Name: *

Middle Initial:

Title:

Job Title: *

Institution: *

Address: *

City: *

State: *

Zip/Postal Code: *

Country: *

Phone: *

Fax:

EAP Website Address:

Your EAP website address. Remember to include http:// at the beginning of the address.

Program Setting: *

K-12

College or Univeristy

Community College

Teaching Hospital

Internal or Combined Program: *

Internal*

Combined**

* Internal Model of Service: When EAP Staff is employed by the educational institution.

** Combined Model of Service: When the EAP director is employed by the educational institution, but his/her staff may be contracted out to provide EAP services. This may be on and/or off site and satellite locations.
NOTE: Combined Model requires sponsorship by a member of IAEAPE in good standing who represents an Internal Model of Service.

Statement of Understanding Agreement

All applicants must abide by the Bylaws including Article 1, Section 3, Membership Statement of Understanding. Please read the Statement of Understanding. If you agree with it, click the checkbox above.

CAPTCHA

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