ACEPT Annual Membership Registration

Annual Membership Registration

Please complete the information below in order to renew your annual membership or register as a new member with ACEPT by the end of October.
Name of Site/Organization:
(Please make sure to include Name of Organization in 'Memo' for Payment)
Director of Training:

First NameLast Name
Phone Number:
Format: (000) 000-0000.
Site/Org Email:
example@example.com
Site/Org Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Voting Representative

(Each organization is allowed one vote per membership - please indicate your chosen voting member here. The membership account will be associated with the Voting Representative's email address.)
Voting Representative:

First NameLast Name
Voting Representative Email:
example@example.com
ACEPT Guidelines Agreement
As an ACEPT member, my organization and I hereby support the missions of ACEPT and abide by the ACEPT guidelines.
If you have any questions about the guidelines and/or mission of ACEPT, please contact the ACEPT President at president@aceptchicago.org.
Membership Type

(Please indicate how you want to pay & your memership category.)
Membership Type:
Select your membership option.
How would you like to pay for your membership?
To pay via check (ONLY if company policy necessitates this payment type)

Mail check (with organization/member name indicated on memo line) payable to ACEPT to the ACEPT Treasurer: Greg Harms, Psy.D. 4203 N. Sheridan Rd. #3N Chicago, IL 60613. Please direct questions to treasurer@aceptchicago.org.

Membership Options

Should be Empty:

Annual Membership Registration

Voting Representative

ACEPT Guidelines Agreement

If you have any questions about the guidelines and/or mission of ACEPT, please contact the ACEPT President at president@aceptchicago.org.

Membership Type

To pay via check (ONLY if company policy necessitates this payment type)

Membership Options

Payment Methods