Basic Certified ACT Consultant (CAC) Record Maintenance
MEMBERSHIP FORM

Please click on Submit at the bottom of this form

 

Name:
As you would like it to appear on your ACTCA Membership Certificatep

Company:

Address1:
Address2:
Address3:

City:   State:     Zip:

Country:

Phone:   Fax:

Email: 
Web Site:

What would you like the ACTCA to do for you?

Please list me on the Web list of ACTCA members

Please acknowledge my membership in the ACTCA to prospective clients who may call the ACTCA

I would like to participate as an officer in the ACTCA

I already hold other ACT! Certification

If you have previously completed and submitted an ACTCA application, contact ACTCA at (202) 329-1090 to verify your eligibility to take the ACTCA examination for the ACP and ACT.

Please type or print clearly and mail to ACTCA, 510 N Street, SW, Suite 32, Washington DC  20024. This form MUST be accompanied by filing fee of $25, and three references. A check or money order, payable to ACTCA, must be included for the non-refundable one-time membership fee of $25.00 (U.S.). If paying by credit card, complete credit card authorization.

Education and Certifications:

Name and Location of Institution Month and Year of Attendance
Degrees, or Certifications Received
and Date

References:
Give names and addresses of the three persons to whom you have provided ACT! consulting. They must be employers, clients, or professional peers. The reference forms must accompany this application. They will ONLY be contacted to verify your work for them.

Reference 1

Name:

Company:

Address:

City:   State:     Zip: Country:

Phone:   Fax:

Email:  Web Site:



Describe briefly the ACT! work provided

Reference 2

Name:

Company:

Address:

City:   State:     Zip: Country:

Phone:   Fax:

Email:  Web Site:



Describe briefly the ACT! work provided

Reference 3

Name:

Company:

Address:

City:   State:     Zip: Country:

Phone:   Fax:

Email:  Web Site:



Describe briefly the ACT! work provided

Membership and Application Fee

Membership Fees $25 per year for each certification level for membership record maintenance, and verifying membership in the ACTCA to your contacts.
This could result in many emails and calls to attend to on your behalf.
Check the memberships you would like to apply for  The application fee includes the first year of membership in that level

Certification Level Requirements Membership/Application Fee per year Check Certified ACT Consultant Must be an ICC ACC or pass basic exam $25/year CAC ACT Certified Professional Must pass professional exam $25/year ACP ACT Certified Trainer Must pass trainer exam $25/year ACT TOTAL $ How would you like to pay?

Credit Card:  Orders processed by next business day.
Card No:  
Expiration Date (Mm/Yy):
Billing Address for Credit Card (if different from Shipping address)
 Name appearing on card
 Street
Apartment/Suite
City, State, Zip-code
Country

I have authorized this charge, and agree to pay for the merchandise specified above.

Your Signature is Required
Please Fax this to 888-892-3660 or mail to our address
Merchandise cannot be sent without your signature of approval - for your own protection.

Date _______________

This form will be submitted to an SSL Security Site for encryption. If you prefer, you may call in your card number at 800-319-3190, then print this form and fax it toll free to 888-892-3660

Internet PayByCheck:  Please fill out on-line form. 
Order processed by next business day.  Most secure method.  ICHCKLGO.gif (700 bytes) Check: Order will be shipped upon receipt of your payment from the bank.
This may take a week or so. Click here for
our address. Thank you!
By clicking on Submit, I agree to the above charge for membership in the ACTCA

 

(OFFICE USE ONLY)

Approved _____ Disapproved _____ Date ____________ Reviewed By: ______________

Comments: ________________________________________________________

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