OCCAMFT Membership Application Form - OCCAMFT- Orange County California Association of Marriage and Family Therapists

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OCCAMFT Membership Application Form

Introduction:

We welcome you to join OCCAMFT, the Orange County Chapter of CAMFT, the California Association of Marriage and Family Therapists.

MEMBERSHIP POLICIES: State CAMFT membership is required prior to OCCAMFT chapter membership (for State CAMFT membership information: www.camft.org or 888-892-2638). OCCAMFT offers three membership classifications which are defined in the Annual Fee Schedule. The OCCAMFT membership year is January through December with annual memberhsip renewals mailed to you beginning October 1 each year. New memberships are accepted throughout the year. Upon completion of this online application, you have 2 payment methods: pay online with credit card or checking via PayPal (no account necessary); or, mail check payable to OCCAMFT to our mailing address located at the bottom of the next page. After membership has been completed, members are encouraged to register on www.occamft.org.

ATTENTION: Incomplete applications will delay membership. All new member applications take approximately 30 days to process. You will be contacted by email once your membership is confirmed.

This is a: *

New Member Application for 2010Update Profile

I am a member of the state CAMFT: *

YesNo

My state CAMFT membership number: *

Last Name: *

First Name: *

Email Address: *

Degree(s):

License # or Intern #: *

License Type or Registration Type: *

License Start Date or Registration Start Date:

License Exp Date or Registration Exp Date:

Mailing Address: *

Preferred Phone: *

Involvement Opportunities:

I am interested in serving on a committee of the OC CAMFT Board of DirectorsI am interested in serving on the OC CAMFT Board of DirectorsI have a special talent that I would like to share with OC CAMFT (ex. Computer Skills-Event Planning-Marketing/Public Relations)

Payment Table:

OC CAMFT membership runs from January to December of the same year. Membership dues for NEW MEMBERSHIPS are offered on a prorated basis. All memberships expire on December 31st, so every member must renew annually. If you have a question, email billing@occamft.org. If you are applying for NEW MEMBERSHIP, please use the following chart to determine your dues. You can pay via Credit Card or Check. Payment information is on the next page after you press submit.

Month	Licensed or Associate	Pre-Licensed: Student or Intern
January	$75.00	$30.00
February	$68.75	$27.50
March	$62.50	$25.00
April	$56.25	$22.50
May	$50.00	$20.00
June	$43.65	$17.50
July	$37.50	$15.00
August	$31.25	$12.50
September	$25.00	$10.00
October	$18.75	$7.50
November	$12.50	$5.00
December	$6.25	$2.50

Payment Option (See Chart for Amount): *

I will pay for Pre-Licensed Membership by PayPal or Credit Card.I will pay for Clinical or Associate Membership by PayPal or Credit Card.I will pay for Pre-Licensed (See Table) Membership by check.I will pay for Clinical or Associate Membership (See Table) by check.

Please enter the 4 digit black letter code: