Your credit card will be charged $8.75 every 3 months until you tell us to terminate your membership.

$40 for a twelve-month membership through April 30, 2011.

Please copy, paste and email to NJACBT@aol.com or print out the application below and mail it to

NJ-ACT, P.O. Box 2202, Westfield, NJ 07091.

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NJ-ACT Membership Application

I am licensed for independent practice in New Jersey or I hold a permit to practice psychology in New Jersey or I am a NJ resident, licensed in another state.   

_____ I have paid online

_____ $40 is enclosed for a twelve-month membership through April 30, 2011.

                       Name and Degree ___________________________________ County _________

Permit or Licensed As: __________________________ Number ______________

Primary Office Address _______________________________________________

Primary Town ________________________________ State ___ Zip __________

Primary Phone (____)_____-_______ E-mail*_______________@____________

Secondary Office Address**___________________________________________

Secondary Town**___________________________ State**___ Zip**________

Secondary Phone**(____)____-_____ Secondary Office County**____________

 *We must have your e-mail address if you wish to receive electronic articles, member discussions and warnings of when workshop registration will be closing.

**Optional categories. If you are a licensed member and you wish to have your secondary office listed, please provide full address, town, state, zip, phone number, and county.

To be listed in our website member directory sign and mail or email the following statement:

 View directory 

Do you want your private practice(s) to be listed on our website Member Directory? (members licensed for independent practice only, please check one)

____ Yes, a complete listing -  street address, town, and telephone number.

____ Yes, a partial listing - town and telephone number, without street address.

____ No website listing, please.

 “I affirm that my profession’s licensing board permits me to practice independently and without restriction, and there is no complaint against me pending with my licensing board. I also agree to inform NJ-ACT immediately if any of these stipulations change.”

                         ____________________________________     ____________

                         Signature                                                                     Date

                                                                 

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