Name: LASACT Membership
SKU: 120
Availability: InStock

LASACT • P.O. Box 80235 • Baton Rouge, LA 70898-0235

(225) 766-2992 • Fax (225) 766-8552 • admin@lasact.org • lasact.net

Please fill out all the required fields.

Dues cover calendar year - January through December. Convenience fee of $5 is added to all credit card and PayPal payments. Membership Application and International Certificates CANNOT be processed until LASACT has received payment and this form.

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Work Phone Number*

Cell Phone*

Email*

Employer

Office Address

Street Address Address Line 2 City State ZIP Code

ADRA and LASACT Credentials

Please check all items that apply to you in the section below. Fill in the appropriate information regarding credential numbers and expiration date.

ADRA Credentials

Other Credentials

LPC
LMFT
LCSW
LMSW

LASACT Certificates

AADC
CCJP
CCDP-D
CCDP
PRSS
SAP

LAC No.

LAC Expiration Date

CAC No.

CAC Expiration Date

RAC No.

RAC Expiration Date

CIT No.

CIT Expiration Date

LPP No.

LPP Expiration Date

CPP No.

CPP Expiration Date

RPP No.

RPP Expiration Date

PSIT No.

PSIT Expiration Date

CCS No.

CCS Expiration Date

CCGC No.

CCGC Expiration Date

ATA No.

ATA Expiration Date

LPC No.

LPC Expiration Date

LMFT No.

LMFT Expiration Date

LCSW No.

LCSW Expiration Date

LMSW No.

LMSW Expiration Date

AADC No.

AADC Expiration Date

CCJP No.

CCJP Expiration Date

CCDP-D No.

CCDP-D Expiration Date

CCDP No.

CCDP Expiration Date

PRSS No.

PRSS Expiration Date

SAP No.

SAP Expiration Date