International Christian Counselors Alliance Membership Application  You Must hold a Christian Counseling Certificate from a recognized organization in addition to a degree. Do not complete this application if you have applied for the ICCA Certificate Program P.O. Box 1060, Rogers, Arkansas 72757-1060    501- 636-7497   800-494-7497  http://www.freedomministries.com/icc.html Please type or print.  It is important to complete all information. To copy, select (highlight) this whole page by using "control A." After it is selected, use "control C" to copy.                                    Go to a blank page on your word processor and use "control V." PART I: Personal   1. Last Name ______________________First Name ______________________Middle _____________ 2. Address __________________________________________________ P.O. Box ________________ 3. City_________________________State________(Country)_______________Postal Code ________ 4. Home phone _________________ Office ________________ E-Mail _________________________ 5. Date of Birth (mm/dd/yy)  ______ /_____ /_____     SSN/SIN ______-______-______  Sex ______ 6. Church membership:_________________________________________________________________   PART II: Christian Counseling Certificate Information   1. Issuing Organization ________________________________________________________________ 2. Contact Person ___________________________________________ Phone ___________________ 3. Expiration Date of Certificate ______________________   PART III: Education   College Attended  Location  Dates  Degree 1. . . . 2. . . . 3.  . . .  PART IV: Membership Fees (check one)    1. ___ I have enclosed $50 for the first year. 2. ___ I wish to apply for a lifetime membership and I enclose $350.00.   (Will not be processed without the proper fees) PART V: Credentials   1. Credentials currently held:  Ministerial License ____    Ordination ____    Other _____    None _____   (Define if Other ____________________________________________________________________) 2. With what organization? _____________________________________________________________ 3. Do you plan to apply for credentials with Concepts of Freedom Ministries?    Yes____    No  ____    (For details on CFM credentials, please go to the web page <http://www.freedomministries.com/ordination.html> or contact the office.) 4. Do you plan to apply for membership with Freedom Christian Ministries Association? Yes___  No__  5. If yes, will the application be for your  counseling practice _____     church _____     both _____    (For details on FCMA membership, please go to the web page <http://www.freedomministries.com/affiliate.html>    or contact the office.) Part VI: Signature This application must be completed and signed before it will be processed.  If you have questions about the application process, please call or email.  ______________________________________________                                 __________________ Signature of applicant                                                                                   Date signed     Please help us serve better: 1.  How did you hear about the International Christian Counselors Alliance ?_______________________ 2.  Why did you choose ICCA?______________________________________ 3.  Suggestions or comments: ___________________________________________________________ ___________________________________________________________________________________   ICCA Use Only Approved:    Yes                  No                      Yes with conditions  ____________________________________________________________________________________   CFM-ICCA Form 201                                                                           ©2000 Concepts of Freedom Ministries, Inc.