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2008 RECAMFT MEMBERSHIP APPLICATION/RENEWAL
PLEASE PRINT CLEARLY!
Complete all
information:
Renewal
New Member Today’s
date:
____________________________________
NAME:
_____________________________________________________________________________
(last)
(first)
MAILING ADDRESS: _________________________________________________________________________
(Where you want chapter mail
sent) (street or P.O. Box)
________________________________________________________________________________________
(city)
(zip)
Please send my newsletter by email only
OFFICE ADDRESS:
________________________________________________________________________________________
(If different from
above)
________________________________________________________________________
(city)
(zip)
ADDRESS: 2nd
OFFICE:
__________________________________________________________________
(street or P.O. Box)
__________________________________________________________________
(city)
(zip)
EMAIL/WEBSITE ADDRESS:
(publish
on-line or in Directory: yes no )
_________________________________________________
TELEPHONE:
OFFICE_______________________________ HOME
(Will not be published)_________________________________
Your name and newsletter mailing address is
public information, like BBS information. The membership roster is confidential
but mailing labels are available for a fee to members and organizations.
You MUST provide
your license/intern registration number (unless you are a student) and your
state CAMFT number. You MUST be a member of state CAMFT to join RECAMFT.
_______________
_______________________________
_______________________
DEGREE LICENSE/REG.
TYPE & NUMBER STATE CAMFT
NUMBER STUDENT
_______________
_____________________________________________________________________
INTERN REG. # SUPERVISOR NAME & LICENSE TYPE/NUMBER
(required for
Directory or online listing)
MEMBERSHIP Full
Clinical Member (LMFTs
Only)
$50.00
& DIRECTORY Affiliated Professional (LCSW, Ph.D, Psy.D.
other)
$50.00
Pre-Licensed Member
(Student/Intern)
$25.00
On-line Referral Listing
$60.00
TOTAL AMOUNT
ENCLOSED
$________
For CAMFT State application
form and/or information, call (858) 292‑2638, or join online:
www.camft.org
MEMBERSHIP YEAR BEGINS JANUARY 1ST,
SO PLEASE RENEW BY JANUARY 1ST. PRIVILEGES OF MEMBERSHIP EXPIRE
JANUARY 31ST.
Make checks payable to
RECAMFT and mail to:
RECAMFT Membership
P.O.
Box 2443
9/28/07
Sebastopol,
CA 95473
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