Lasact Membership Form PDF Details

Attention members of the Lasact Association- it's time to renew your membership for another wonderful year! We're thrilled to provide you with a hassle-free way to submit your annual form, so that you can keep supporting our organization and its values. As an association dedicated to providing access, education and support services for the Latinx Advisory Services community, we rely on our members' continued participation and donations. Stay connected in style with this digital version of the Lasact Membership Form. Keep reading to learn more about what you need to do in order to continue assisting us throughout 2020.

QuestionAnswer
Form NameLasact Membership Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesapplication lact download, application lact online, lasact renewal, membership application lact

Form Preview Example

Louisiana Association of

Substance Abuse Counselors and Trainers, Inc. (LASACT)

P.O. Box 80235 • Baton Rouge, LA 70898-0235 • Phone: 225.766.2992

Fax 225.766.8552 • e-m ail: adm in@ 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. Mrs.

 

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Title

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

Middle

MAILING ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP

EMPLOYER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP

PHONES: O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX

 

 

 

 

 

CELL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*************************************

 

 

 

 

 

 

 

 

 

ADRA Credential(s) - Check all that apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAC

 

CAC

RAC

 

CIT #

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LPP

 

CPP

RPP

 

PSIT#

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CCS #

 

 

 

 

Expiration Date

 

 

 

 

CCGC #

 

 

 

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Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASACT Certificate(s) Check all that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AADC #

 

 

 

 

 

 

Expiration Date

 

 

 

CCDP-D #

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CCDP #

 

 

 

 

 

 

Expiration Date

 

 

 

 

 

CCJP #

 

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Types of Right to Practice Credential(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LPC #

 

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

LMFT #

 

Expiration Date

 

 

 

 

 

LCSW #

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

LMSW #

 

Expiration Date

 

 

 

 

 

If credential is not in above list(s), fill in type / number / expiration date here:

Dues cover calendar year - January through December

Individual M embership $90.00 Ë Student M embership: $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.

Dues payment Options:

TOnline at www.lasact.org using PayPal and faxing application form to 225.766.8552

TBy check or money order sent through U.S. mail to: LASACT – P.O. Box 80235 – Baton Rouge, LA 70898-0235

TBy filling in the Credit Card information requested below and mailing to the above address or faxing to 225.766.8552.

TBy 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 & #:

 

Expiration Date:

Security Code on back of card

Billing ZIP Code

Rev: November 8, 2011

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