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Get LA LASACT Membership App 2011-2024

766. 2992 Fax 225. 766. 8552 e-mail admin lasact. org w eb site w w w. lasact. org MEMBERSHIP APPLICATION - LACT STUDENTS G new membership G renewal of current membership G reinstatement 25 fee NAME Mr. 00 Student Membership 45. 00 - Download student form at www. lasact. org Full tim e student status m ust be verified - m axim um for student m em bership is two years. 8552 T By check or money order sent through U.S. mail to LASACT P. O. Box 80235 Baton Rouge LA 70898-0235 T By filling in the Credit Card information requested below and mailing to the above address or faxing to T By phoning Credit Card information to 225. 766. 2992 and faxing this form to 225. 766. 8552 Membership Applications - new or renewal - cannot be processed until LASACT receives this Form. Credit Card information Credit Card Type Security Code on back of card Rev November 8 2011 Billing ZIP Code. Ms. Other Title Last First Middle MAILING ADDRESS Street/P. O. Box City State ZIP EMPLOYER OFFICE ADDRESS Street PHONES O H CELL FAX ADRA Credential s - Check all that apply LAC CAC RAC LPP CPP RPP CCS Expiration Date ATA LASACT Certificate s Check all that apply AADC CCDP CIT PSIT CCGC CCDP-D CCJP Other Types of Right to Practice Credential s LPC LMFT LCSW LMSW If credential is not in above list s fill in type / number / expiration date here Dues cover calendar year - January through December Individual Membership 90. Louisiana Association of Substance Abuse Counselors and Trainers Inc* LASACT P. O. Box 80235 Baton Rouge LA 70898-0235 Phone 225. Dues payment Options T Online at www. lasact. org using PayPal and faxing application form to 225. 766. 8552 T By check or money order sent through U*S* mail to LASACT P. O. Box 80235 Baton Rouge LA 70898-0235 T By filling in the Credit Card information requested below and mailing to the above address or faxing to T By phoning Credit Card information to 225. Dues payment Options T Online at www. lasact. org using PayPal and faxing application form to 225. 766. 8552 T By check or money order sent through U*S* mail to LASACT P. O. Box 80235 Baton Rouge LA 70898-0235 T By filling in the Credit Card information requested below and mailing to the above address or faxing to T By phoning Credit Card information to 225. .

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