membership application membership app 0… · oca region: email address: please print clearly, this...
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Credit Card Information
VISA MasterCard
#
CVV Code Exp. Date
Signature
Membership Application
Dues
DivisionsYou may join as many divisions as you like.
Divisions Total $
Total Amount Due $(Dues + Divisions)
Check all that apply: New Member Renewal Information ChangePlease print clearly so your information is printed accurately in our membership directory:
If you prefer, enroll online at: oklahomacounseling.org
Preferred Mailing Address:
Preferred Contact Number: ( ) OCA Region:
Email Address:Please print clearly, this address will be used to send you newsletters and information.
NW C NE SW SE
Dr. Mr. Mrs. Ms. (Last) (First) (MI)
(Number & Street) (City, ST) (Zip Code)
$50 Professional$30 Regular (Individuals in a counseling role with less than a master’s degree)
$0 Student (Individuals pursuing a master’s degree in counseling or closely related field. Students may now join for free. We still need your information to complete an application.)
$40 Retiree (Individuals retired from the counseling profession and receiving no compenstion for provision of services)
$10 Oklahoma Association of Addictions Counselors (OAAC)$ 5 Oklahoma Christian Counselor Association (OCCA)$10 Oklahoma Association of Counselor Education & Supervision (OACES)$10 Oklahoma Mental Health Counselor Association (OKMHCA)$ 5 Oklahoma Association for Multicultural Counseling & Development (OAMCD)$ 5 Oklahoma Professional School Counselors Organization (OPSCO)$ 5 Oklahoma Association for Lesbian, Gay, Bisexual, & Transgender Issues in Counseling (OALGBTIC)$ 5 Counseling Association for Military, Oklahoma Veterans and Families (CAMOVAF)
Make Check Payable To:Oklahoma Counseling AssociationMail Payment:Angela Easter3328 E. 7th St.Tulsa, OK 74112Questions: [email protected]
OCA Use Only:Received by:
Date:
2014 MembershipForm814-j