Applicants who cite postgraduate degrees must send official transcripts of

such degrees.
Official transcripts in this context are interpreted as
original transcripts signed by the university. The Secretary will accept
photocopies of degree and qualification certificates but reserve the right to
have sight of the actual certificate rather than a photocopy.
This application form should only be returned to the Secretary when the
applicant has filled in the form completely. The Secretary will not accept
photocopies from referees. Applicants are advised to retain a full copy of
their completed application form (in case of it getting lost in the post).
The completed form should be returned to: The Secretary, XUAL Community,
Kilmatogh, Co. Leitrim, Rep. Of Ireland.
FEES

A scrutiny fee of 70 is enclosed (Scrutiny fees are non-returnable)

A registration fee of 150 is payable when your application has been
accepted.
Annual membership renewal fee of 150 is enclosed (Payable by registered
members every year after their first year of membership)

Personal Details:
Mr.

Mrs.

Miss

Ms

Dr.

Professor

Other _____________________________________________ (Please specify)

First Name(s) _________________________________________
Surname _________________________________________
Date of Birth

Previous Surname, if any _________________________________________

(Please show surname which appears on relevant certificates if it differs

from what you use now.)
Address (to which all correspondence should be sent)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Telephone No. ___________________________
2

I consent to my name and contact details appear on the list of Registered

members of the XUAL Community available to the public
Yes

No

Have you ever been a Registered Member of the XUAL Community?

Yes
No
If yes, please indicate year of registered membership. ______________
(Please note that you only need to complete pages 1 through to 6 of this form
if you have already been a Registered member of the XUAL Community )
Have you ever been refused membership of a scientific research group?
Yes

No

(If yes, please enclose details on a separate sheet of paper.)

Have you been the subject of disciplinary proceedings by any professional
body?
Yes

No

(If yes, please enclose details on a separate sheet of paper.)

Have you ever been convicted of a criminal offence?
Yes

No

(If yes, please enclose details on a separate sheet of paper.)

Do you know of any reason why you should not be granted Registration?
Yes

No

(If yes, please enclose details on a separate sheet of paper.)

I declare that, to the best of my knowledge and belief, the foregoing

statements are true.
Signed ________________________________________
Date _________________________

RELEVANT QUALIFICATIONS IN SCIENCE

Please list your degree(s) and qualifications in a relavant scientific field
and give them in reverse chronological order, starting with the last.
Full title
of the
course as
named by
the degreeawarding
authority

Degree and
grade
obtained

Type of
study and
assessment
methods

Name of
College or
other
degreeawarding
institute
of higher
learning
Date
Started
Date
awarded

Notes
Title of the course
Please give the full title of your degree exactly as shown on the degree
certificate including such descriptions as Joint Honours or Combined Studies.
Degree and grade obtained
Please give the abbreviated title of your degree
classification, for example, B.A. Hons, MPsychSc, PhD.

with

your

honours

Type of study and assessment methods

Indicate whether your degree involved course work, empirical research, or
some combination, and how it was assessed, for example:
- Course work & examination
- 60% course & exam, 40% thesis
- Research & thesis
- Course work & continuous assessment
If the spaces provided are insufficient, please use a separate sheet of paper
to accommodate additional information and attach the sheet to this
application form.
APPLICATION AND UNDERTAKING
I apply for entry to the Register of members

If accepted, I undertake to comply with the Memorandum and Articles of

Association of the XUAL Community (including Regulations concerning the form
and keeping of the Register of members) and to comply with the Code of
Professional Ethics.
While I am a Member of the Community, I undertake to advance the aims of the
XUAL Community as far as I can.
I undertake that, on receiving a notice from the Secretary that, in accordance
with one or more articles of the Memorandum and Articles of Association, that
I am no longer a member of the Community, I will immediately cease to use any
privileges of membership and will return any books, papers, certificates or
other property belonging to the Community, or for which the Community is
responsible, in my possession or entrusted to me.
I confirm that, to the best of my knowledge and belief, the information I have
given is correct and that I am a fit person to belong to the XUAL Community.

Signed ________________________________________
Date _________________________
5

Notes
Documents:
The XUAL Community cannot accept responsibility for valuable documents
entrusted to the post. Please send photocopies only of degree certificates
certifying that you have passed the appropriate courses in support of your
application. Original transcripts of courses or other authoritative document
from the college or university are required.
Translations:
If references, certificates or abstracts are sent in any language other than
English, applicants must provide authenticated translations of the documents.
Referees:
Registered members are reminded that their current Registration is subject to
annual registration fees. Failure to pay the fee on time may result in the
member's name being removed from the Register list for that year which also
means they cannot support new member applications as referees.
Supervisors:
Each period of work/study/training that supports your application for
Registered membership of the XUAL Community must be verified by a supervisor
who had direct supervision of your work or training during that period.
Please refer to the current guidelines for Registration for more detailed
information.
Use separate pages when necessary. Make sure that those extra pages are
securely attached to the rest of your application.
VERIFICATION OF QUALIFICATIONS
ROUTE 1 : With effect from 1st February 1969, an entrant to the register must be
a graduate of a recognised college, and must hold
an accredited graduate qualification in psychology, pharmacology or
relevant science and/or postgraduate science qualification;
A.

To be completed by the Applicant

Name of Applicant _____________________________________________________

Graduate Study/Training
_________________________________________________________________________
(Give name of course/college/awarding body)
6

Dates of Training:
From_______________________________To___________________________
Qualification ____________________________________
Date of Award ___________________________
Area of Applicant's Speciality:
Counselling

Clinical

Educational

Other ___________________________
(Please specify)

In the case of applicants who obtained their qualifications overseas,

supervisors should indicate their status within the college or institute
of higher learning of their own country.

Name of college or institute of higher learning____________________________

_________________________________________________________________________
Your application will not be processed unless the following pages are
carefully completed and signed by appropriate referees.
B.
To be completed by two other XUAL Registered members in support of the
applicant

The applicant has set out the above postgraduate study/training for which I
have had direct experience of them during that period.( Please append your
signature below)
I support __________________________s application for Registered membership
of the XUAL Community on the basis of the study/training detailed above, and
confirm that the applicant undertook the above study/training between the
dates indicated, that the study/training was in the relevant scientific area
accepted by the XUAL Community, and that the applicant performed the
study/training in a professional and competent manner.
1st Referee's Name _____________________________________ (Block capitals)
Membership No.

Address and contact details ______________________________________________

_________________________________________________________________________
_________________________________________________________________________
7

XUAL Community position held ____________________________________________

Signed _________________________________ Date _____________________
2nd Referee's Name _____________________________________ (Block capitals)
Membership No.

Address and contact details ______________________________________________

_________________________________________________________________________
_________________________________________________________________________
XUAL Community position held ____________________________________________
Signed _________________________________ Date _____________________

EMPLOYMENT HISTORY RELEVENT TO APPLICATION

Please list the jobs/work positions you have held since obtaining your
qualifications in reverse chronological order, starting with the last.
(Indicate your current job/work position first.)
Job Title or
Occupation

Employer

Full-time

Part-time
8

Hours per
week
Weeks per
year
Date from

Date to
Supervisors
Name

Notes
Job title or occupation:
Indicate with a bracket or in some other way any appointments you have held
(or hold) concurrently.
Dates:
Give month and year. It will be assumed you were not working during any
period not accounted for in your employment record.
Supervisor:
Your Supervisor should be the one who supervised your work in your field.
If the spaces provided are insufficient, please photocopy this page to
accommodate additional information and attach the photocopied page to your
application.

VERIFICATION OF SUPERVISED WORK EXPERIENCE

ROUTE 2 : With effect from 1st February 1969, an entrant to the register must be a
graduate of a recognised college, and must hold
-four years work experience in a relevant field of science.
9

A.

To be completed by the Applicant

Employers Name and Official Job Title/Occupation

________________________________________________________
Duties/Key Skills
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
(List duties and key skills acquired)
Date From _______________________ To
Full Time

Part Time

_______________________

If part time please specify the hours per week

Weeks per year

___________________

____________________

Name of Supervisor___________________________________________________
Supervision Arrangements (frequency, duration)
_____________________________________________________
B.

To be completed by the Supervisor

The applicant has set out above the period during which I had direct
experience of his/her work. (Please append your signature.)
I support __________________________s application for Registered membership
of the XUAL Community on the basis of the work detailed above, and confirm
that the applicant undertook the above duties between the dates indicated,
that the work was in the relevant area of science, and that the applicant
performed the duties in a professional and competent manner.
*Supervisors Name ______________________________________
Signed ____________________________________________________
Date _____________________
Organisation, address and contact details
________________________________________________________________________
10

________________________________________________________________________
________________________________________________________________________
Position held____________________________________________________
Are you a Registered Member of the XUAL Community?
Membership No.

Yes

No

Notes
Supervisors in support of an application for Registered membership must
verify that they have supervised and had direct experience of the period of
work cited by the applicant.

Checklist of items for the attention of applicants

Please tick to confirm.

Have you read the current guidelines for Registered membership in the
leaflet provided?

Separate sheets you may decide to attach.

Photocopies, not originals, of degree and qualification certificates.

Official transcripts
postgraduate level.

of

degree

and

qualifications

obtained

at

In the case of applicants from abroad, authenticated translations in

English language provided, if relevant
Supervisors reports
The correct fee
Have you completed all pages relevant to your application?
Have you made a copy of your completed application?

11