Application for Membership

APPLICATION FOR MEMBERSHIP
in the SCKMHCA

MEMBERSHIP INFORMATION
	Ms. Mr. Dr.
Full Name :
Email Adress:
Mailing Address:
City:
State:
Zip Code:
Home Phone:
County:
WORK INFORMATION
Employer:
Work Setting:
Position/Title:
Work Phone:
County:
FAX:
GENERAL INFORMATION
National Certifications:
Other Credentials:
Kentucky Certification or other Licensures:
Professional Organizations:
EDUCATION
Please select the highest degree earned:	Associate Bachelors Master Doctorate Other:
Year Completed:
Degree Area:
PAYMENT
By submitting this form below, you will be redirected to choose your type of membership, here are the different types and their cost:
MEMBERSHIP FEES	Professional: $15 Non-professional: $10 Student & Retired: $5
By checking this box, I, as a member of the South Central Kentucky Mental Health Couseling Association, I agree to abide by the AMHCA Code of ethics (amhca.org) and stipulate that all information provided above is correct. Make checks, or money order payable to SCKMHCA and mail to (NO CASH PLEASE!): Jillian Tauffener, Treasurer - SCKMHCA 210 Lindsey Wilson St. Columbia, KY 42728 Email: treasurer@sckmhca.org

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