____ New Member ACES/ACA
____Adding ACES Division
ACA Membership # ___________
Source Code: N9XDCE
Social Security Number:
_________________________
First Name _________________ M.I. _____ Last Name _______________________
Mailing Address:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
City - State - Zip - Country
Organization: ___________________________________________________________
Home Phone: ________________________________
Work Phone: ________________________________
FAX: ______________________________________
E-mail: ____________________________________
By joining ACA, you agree to abide by ACA's Bylaws and other governing documents, as well as ACA's Code of Ethics and do qualify for the membership category selected.
* Membership in ACA is required. The definition for a New Professional is a current Student member who has graduated in the last 12 months. This status is good for one year.
If you are an ACA member already, include your membership ID # to make it easier for ACA personnel to track the membership information.
DUES
|
|
Professional |
New Professional*/ Student/Retired |
|
ACA |
$135.00 |
$85.00 |
|
ACES |
$60.00 |
$25.00 |
|
Total |
$195.00 |
$110.00 |
*Students: Please indicate expected date of graduation.
(Month/Year) ____________________/__________________
PAYMENT METHOD
Amount Remitted: $ ____________________
_____ Check or money order made payable to ACA in U.S. funds, enclosed.
Charge:
_____ Visa _____ MasterCard
_____ American Express _____ Discover
__________________________________________________________
Cardholder's Name (Print)
__________________________________________________________
Credit Card Number Exp. Date
__________________________________________________________
Authorized Signature Date
FOUR EASY WAYS TO ENROLL
1. Mail application and payment to:
American Counseling Association
P. O. Box 791006
Baltimore, MD 21279-1006
2. FAX with credit card information to:
800.473.2329 or 703.823.0252
3. Enroll with credit card via internet:
www.counseling.org
4. Call 800.347.6647 Ext. 222 or
703.823.9800 Ext. 222
--------------------------------------------------------------------------------
To serve you better, ACA requests this information about you. Please complete
the following which will remain in your confidential member record.
Circle the ones that apply.
|
Current Position
1. Counselor
2. Counselor Supervisor
3. Counselor Educator
4. Administrator
5. College Student Affairs Specialist
6. Research/Evaluation/Measurement Specialist
7. Paraprofessional
8. Other __________________
9. Student
Birth year __________________ |
Work Setting
1. Elementary School
2. Middle/Jr. H.S.
3. Secondary/Senior H.S.
4. Junior/Community College
5. College/University
6. Rehabilitation Prgm/Agency
7. Association/Foundation
8. Parochial/Proprietary Inst.
9. Career Dev. Prgm/Ctr.
10. Government
11. Correctional Facility
12. Private Counseling Ctr/Practice
13. Community Agency
14. Business/Industry
15. VocationalTech Sch.
16. Military Installation
17. Pastoral/Religions |
|
Education
1. Doctorate
2. Education Specialist
3. Master's
4. Bachelor's
5. Associate/Certificate
6. Other ___________________ |
Gender
1. Male
2. Female |
|
Annual Salary
1. $ 9,999 or less
2. $10,000-$19,999
3. $20,000-$29,999
4. $30,000-$39,999
5. $40,000-$49,999
6. $50,000-$59,999
7. $60,000-$69,999
8. $80,000-$89,999 |
Household Income
1. $29,999 or less
2. $30,000-$49,999
3. $50,000-$69,999
4. $70,000-$89,999
5. $90,000 or more
|
|
Ethnicity
1. African American
2. Asian
3. Native American
4. Hispanic/Latino/Latina
5. Caucasian
6. Other ____________________ |
Relationship
1. Single
2. Married
3. Life Partner
4. Divorced
5. Other __________________ |
|
Credentials Held Certification
1. NCC
2. NCCC
3. NCSC
4. NCGC
5. CCMHC
7. CRC
8. Other _____________________
9. ACS
10. CFT
11. MAC |
Licensure
1. CCMH
2. CMHC
3. CPC
4. LCMHC
5. LCPC
6. LMHC
7. LMHP
8. LPC
9. LPCC
10. LPCMH
11. LPCPP
12. PC
13. PCC
14. LMFC/LMFT
15. Other ___________________________ |
