LASACT Membership Form

LASACT Membership Form

P.O. Box 80235 Baton Rouge, Louisiana 70898-0235 | www.LASACT.org
Membership Year: January - December 2026
Submission of this form indicates a clear understanding that international certificates will be processed as appropriate upon receipt of these forms. It also indicates an understanding that LASACT membership assures eligibility for the IC&RC International Certificate for applicants with an LAC, CAC, RAC, LPP, CPP, RPP, AADC, CCS, CCJP, CCDP, CCDP-D, or PRSS. LASACT membership renewal fee is $90. Total for reinstatement of membership status after March 31, 2026 is $115. If you fall into any of the below categories, be sure to review the following:
- Louisiana Addiction Counselor Training (LACT) Program students — membership MUST be kept current in order to continue to receive the discounted tuition rate. Failure to do so will result in loss of student member status.
- SAP’s qualified through testing with LASACT — you MUST keep your membership current in order to keep your SAP current and maintain your listing in our records.
Applicant Information
Membership Type*

NewRenewalReinstatement
Name*

Last NameFirst Name/M.I.
Preferred Pronouns
Date of Birth*

MonthDayYear
Date
Email Address (Required)*
example@example.com
Work Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Title
Employer
Race/Ethnicity*

WhiteBlack or African AmericanHispanicAsianAmerican Indian and Alaska NativeNative Hawaiian and Other Pacific IslanderOther
Primary Language Spoken*

EnglishSpanishFrenchGermanChineseVietnameseOther
Armed Forces/Veteran:*

YesNo
Gender*

MaleFemaleNon-Binary
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Education*

High SchoolAssociatesBachelorsMastersDoctorateOther
Credential Information

Type N/A in the first box if you do not have any of the credentials in either table below.

ADRA Credentials*

Rows	Type LAC	CAC	RAC	CIT	LPP	CPP	RPP	PSIT	CCS	CCGC	ATA
No.
Exp. Date

LASACT Certificates/Other Credentials*

Rows	Type AADC	CCJP	CCDP	CCDP-D	PRSS	LPC	LMFT	LCSW	LMSW	SAP	OTHER
No.
Exp. Date

Payment Information

$5 credit card convenience fee will be applied to all membership applications
My Products*
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New Member
Dues are $90 annually and are active during the calendar year from January to December. Price includes: $90 Annual Dues + $5 transaction fee for all credit/debit card payments.

$95.00 Quantity



Renew Membership
Dues are $90 annually and are active during the calendar year from January to December. Price includes: $90 Annual Dues + $5 transaction fee for all credit/debit card payments.

$95.00 Quantity
Item subtotal:$0.00



Reinstate Membership
If a member has not renewed by the end of February 2026, the member must reinstate their now-expired membership starting at the beginning of March 2026. Price includes: $90 Annual Dues + $25 reinstatement fee + $5 transaction fee for all credit/debit card payments.

$120.00 Quantity



Total

$0.00
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LASACT Membership Form

Membership Year: January - December 2026

Applicant Information

Credential Information

Payment Information