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

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OCCAMFT Renewal Membership Application Form

Introduction:

We welcome your interest to RENEW your membership to OC CAMFT, 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. 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. Your account will be approved once your membership is confirmed.

ATTENTION: Incomplete applications will delay membership.

This is a: *

Renewal Membership 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 Directors I have a special talent that I would like to share with OC CAMFT (ex. Computer Skills Event PlanningI have a special talent that I would like to share with OC CAMFT (ex. Computer Skills Event Planning Marketing/Public Relations)

If "Other" is checked, please fill in here:

Payment Table:

OC CAMFT membership runs from January to December of the same year. All memberships expire on December 31st, so every member must renew annually. Renewing memberships are subject to the Annual Fee schedule and are due by January 31, 2010. All renewal memberships received after this date are subject to a fee of an additional $10. If you have a question, email billing@occamft.org. You can pay via Credit Card or Check. Payment information is on the next page after you press submit.

Year	Licensed or Associate	Pre-Licensed: Student or Intern
2009	$75.00	$30.00

Payment Option (see chart for amount): *

I will pay for Pre-Licensed Renewal Membership by PayPal or Credit Card.I will pay for Clinical or Associate Renewal Membership by PayPal or Credit Card.I will pay for Pre-Licensed Renewal Membership by check.I will pay for Clinical or Associate Membership Renewal by check.I have already paid for Pre-Licensed RENEWAL Membership.I have already paid for Clinical or Associate RENEWAL Membership.

Please enter the 4 digit black letter code: