2005 Membership Directory To Be Released in March; Membership Fees Due by 2/28

For all who are involved with the Fellowship of Christian Counselors:

The 2005 FCC membership fees are due by 2/28/2005. These membership fees enable the Fellowship of Christian Counselors to provide CEUs and other member benefits including its upcoming member directory.

Please pay your dues in a timely fashion as we prepare to release the member directory in March.
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MEMBERSHIP APPLICATION FOR
FELLOWSHIP OF CHRISTIAN COUNSELORS – DIRECTORY 2005

Please complete the information below (copy and paste into a word document) and return to Gret Machlan, 2121 St. Joseph Blvd. Fort Wayne, IN 46805 or by e-mail; mailto://lgmachlan@comcast.net. The directory information will be made available to all members of FCC. Please send updates when there are changes.

Include check for annual dues: Professionals: $25 / Full-time Students $10
Checks payable to: Fellowship of Christian Counselors


Name: ___________________________________

Credentials: __BA __BS __BSW __ MA __MS __MSW __ RN __LPN __ MD __PhD __PsyD __M Div __ LMFT__ Student (specify grad, undergrad, and school): ________________________
Other (Specify): ________________________________________________


Agency/ Counseling Practice:______________________________________

Address: ______________________________________

City: _______________________ State: _______ Zip: ____

Mailing Address (if different from above): _________________________

City: _______________________ State: _______ Zip: ________

Telephone: Home: ( ) ________________ Office: ( ) ____________
Cell: ( ) _______________ Fax: ( ) _____________
TDD/TTY: __________________

E-Mail: _________________________ Web-page: ____________________

Days/Hours (open for business): ________________________________

Therapeutic Services / Specialties: ________________________________

Fluent in languages other than English? ________________________________

Other professional organization membership: ____________________________

Fees / Third Party Reimbursement: ___________________________________

Church Affiliation: ____________________

For office use only: Membership dues paid: Date: Directory: Initial: