ACTCA Membership Form

Certified ACT Consultant (CAC)
Member Record Maintenance

Membership: * New Member - first time application information
Existing Member - renewal and information update
First Name: *
Last Name: *
Company or Trade Name:
Address: *
City: *
State: *
Zip: *
E-mail Address: *
Country:
Phone Number: *
Fax Number:
Mobile Number:
Your Web Site:
What more can the ACTCA do for you?:

List the benefits you would like from Membership.

Please list me on the Web page list of ACTCA Members
Please refer me to prospective customers who call ACTCA from your area:
List ACC or other ACT! Certification and Year obtained.
ACCs do not have to take the examination to be a CAC.
I would like to participate on an ACTCA Committee(s)
ACTCA Committees: Advisory
Convention
Education
Elections
Examination Requirements
Mediation and Jury
Management
Membership
Member Benefits
Media
Science and Technology
User Groups
Highest Level of Education: Primary School
High School Diploma
Some College
Bachelors Degree
Graduate / Masters Degree
If you earned a college degree, please list the major:
References who can attest to your expertise in ACT!
For current ACCs, with automatic approval, enter "NA"		 
Reference 1 Supervisor: *
Reference 1 Organization:
Reference 1 Dates:
Reference 1 Phone:
Reference 1 Email:
Reference 1 ACT! Work Description:
Reference 2 Supervisor: *
Reference 2 Organization:
Reference 2 Dates:
Reference 2 Phone:
Reference 2 Email:
Reference 2 ACT! Work Description:
Best Time to Reach You:

For Prospective Customers who call for a Referral.

Morning
Afternoon
Evening
Any time
Certification Level: * CAC Certified ACT Consultant $35/year
ACT ACT Certified Trainer $100/year
ACP ACT Certified Professional $500/year
Membership Dues Paid via PayPal (opens in new window) $ * Enter the amount that you have just paid.

Bill the credit card yearly until requested by email to stop.
You will receive an email one week in advance, in case you wish to decline.

Automatic Annual Renewal


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I have submitted my fee above, and hereby submit my above information
for one year of membership in the ACT! Consultants Association

Membership Levels, Fees and Benefits

For New Members, the $35 fee includes any charges for any necessary examinations, and the first year of Membership in that level, if accepted.  If you are already an ACC, then the examination is waived.  If you are not, then the examination instructions will be emailed to you.

For Existing Member, the fees are for membership record maintenance, listing your name on the web site, and verifying your membership in the ACTCA to your contacts.  As you receive referrals from the ACTCA web site, you are welcome to ask your contacts to verify your membership and certification with the ACTCA.  The fee helps to pay for the cost of this record maintenance and verification.


You may place ACTCA logos on your web site upon Membership approval.

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Approved _____ Disapproved _____ Date ____________ Reviewed By: ______________

Comments: ________________________________________________________

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