act-app-part1a.docVIP

Please submit an original and one copy of this application, a copy of your current professional license (if available in your locale), a copy of your current curriculum vitae, and your check or credit card payment for $250, to the Academy of Cognitive Therapy, 260 South Broad Street, 18th Floor, Philadelphia, PA 19102, USA. If you are a member in good standing with ACT as a Professional Colleague, Research Scientist or Student Affiliate, you qualify for a discount on your application for certification. Please contact the ACT office to let us know. (For your safety, ACT will no longer accept faxed, mailed, or emailed credit card numbers. If you wish to pay with a credit card, please visit our website, , to apply online.) Date: DEMOGRAPHIC INFORMATION (Please type or print clearly): Name: Business address(es): 1. Setting / Facility Street Suite City State Zip Phone Fax Email 2. Setting / Facility Street Suite City State Zip Phone Fax Email 3. Setting / Facility Street Suite City State Zip Phone Fax Email Home address: Street Suite City State Zip Phone Fax Email Website Please check one: I would prefer to receive ACT mailings to my Business (please specify which if more than one: #) Home How did you hear about ACT? 260 South Broad Street ? 18th Floor ? Philadelphia, PA 19102 Phone: 267.350.7683 ? Fax: 215.731.2182  Web site: ? E-mail: info@ PROFESSIONAL DEGREE Please indicate that you hold an advanced professional degree. This is a professional degree in medicine, psychology, nursing, s