Life-Time Member Application

Life-Time Member Application
Date of Application

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.

Please check the following:

I am either 65 years old OR have maintained CCC-SLP status for 25 years.AND I am currently a BCS-SCF and have been a BRS-F/BCS-F/BCS-SCF for at least 10 years (not necessarily concurrent).
Please list me as Life-Time and choose one of the following options:

I am currently treating clients and maintaining my ASHA CCCs.I am not treating clients, but I remain active in the profession (i.e. research, education, publication, conference presentations).

I attest that I meet the qualifications for Life-Time members status
Signature

Clear
Date

MonthDayYear
Date

Current Specialists can CLICK HERE to log in and pay their application fee ($75 USD) securely online.

Prefer to pay by check? Please send payment to the the ABSCF Administrative Office:

ABSCF
563 Carter Court, Suite B
Kimberly, WI 54136

**Please note that you must continue to maintain your CCC's with ASHA to maintain lifetime member status with the ABSCF.**
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