MEMBERSHIP APPLICATION
for the INTERNATIONAL ASSOCIATION FOR COGNITIVE PSYCHOTHERAPY

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HOW TO APPLY

• By credit card: Fill out the form below and click the "Send Application" button.
• By check: Credit card payments are preferred. However, if you would like to pay by check, fill out this form, leaving the credit card area blank. Then print the application and send it with a check for the total amount due in US dollars to:

  Sharon Freeman, PhD PMHCNS-BC
  IACP Membership Coordinator
  Center for Brief Therapy
  10319 Dawson's Creek Blvd Ste H
  Fort Wayne, IN 46825
  United States of America
  
  Telephone: (260) 969-5583
  Facsimile: (260) 969-5584
  
  

  Please be sure to indicate your member access password after printing, as the password on the computer screen will not appear on the print out.

• Other: Contact Sharon Freeman to request that an application be mailed or faxed to you.
• Note: IACP members receive 5 workshops with their membership. Paid IACP members and ACT members may buy additional workshops in blocks of 5 for $30 USD.
• All Fields marked with * are required.

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APPLICATION

New IACP Application OR if you are renewing, but this is the first time you have have accessed our online services

IACP Renewal

IACP member purchasing additional workshops

ACT member purchasing audio workshops

*Name:
 
*Degree:
 

Mailing Address for membership materials and subscriptions
*Address1:
 
Address2:

*City:
 
*State/Province/Region:
 
*Postal Code:
 
*Country:
 
*E-mail:
  
Include country code on all phone numbers if not in USA.
*Work Phone:
 
Fax:

Home Phone:
 Include home phone in directory

Please check here if you do not want your contact information to be posted on our online password-protected membership directory available only to IACP members.

Billing address same as above?

Yes No

If no, please enter your billing address below:

Billing Address
Address Line 1:

Address Line 2:

City:

State/Province/Region:

Postal Code:

Country:

MEMBERSHIP TYPE

	1 Year	2 Year	3 Year
Individual	$75	$120	$180
Student**	$50
Group**	Number of members:(1-999)
NONE Audio workshops only***	Number of workshops (in sets of 5 for $30 USD)
** Documentation must be provided to prove group and student status.
***You must be a paid member of ACT or IACP in order to purchase additional workshops

Group Rate Calculation Schedule

Members	Rate Per Member
7-49	$11
50-99	$9
100-499	$7
500+	$5

When would you like your membership year to begin? (circle one)

January 2009

January 2010

ONLINE INTERNATIONAL CLINICAL REFERRAL DIRECTORY (New or renewing IACP members only)

Would you like to be listed in the Online Referral Directory	YesNo
DURATION OF ONLINE LISTING

No Listing	1 Year	2 Year	3 Year

*Listing years cannot exceed length of membership

If yes please indicate addresses to be listed at $25/Address per year and select the box next to the address you want listed below,
Only Mailing Address listed above Only office(s) listed below Address listed above and office(s)
Address (2)	Address (3)
City:	City:
Postal Code:	Postal Code:
State:	State:
Country:	Country:
Email:	Email:
Tel:	Tel:
FAX:	FAX:

PAYMENT INFORMATION

*Credit Card:

MasterCard

Visa

*Account Number:
 
*Expiration Date:(mm/yy)
 
*Name on Card:
 


USER INFORMATION
Please select your preferred username and password and keep them in a safe place.
If you are renewing your membership you will need to input your current username
and a password of your choice.  If you previously have registered and have forgotten your password, go to: http://www.cognitivetherapyassociation.org/emaillogin.aspx

*User Name:   
*Password:                   
*Re-Type Password:   

Please list other professional organizations and/or Additional Comments:

*How did you hear about the IACP?
 

Your Total is:   

NOTE:
You will receive an e-mail receipt and additional information within one to two weeks of submitting your application.

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