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

  $60 for a NJ-ACT membership through April 30, 2016.

$20 for a NJ-ACT membership through April 30, 2015.

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.

---

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

_____$60 is enclosed for a NJ-ACT membership through April 30, 2016.

_____$20 is enclosed for a NJ-ACT membership through April 30, 2015.

 

Name and Degree ________________________________________ Office County __________

Permit or Licensed As: __________________________ License/Permit Number ____________

Primary Office Address _________________________________________________

Primary Town ___________________________________ State ____  Zip ________

Primary Phone (____)_________________  Email* __________________@__________

Secondary Office Address _______________________________________________

Secondary Town _________________________________ State ____  Zip ________

Secondary Phone (____)_________________  Secondary Office County ___________

 *We must have your e-mail address to send you our PDF directory, summaries of research studies, member discussions, and notices of opening and closing dates for workshop registration.

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

                                                              

---

[Contact NJ-ACT]

©2014 NJ-ACT. All rights reserved.