Retired Member Application

Retired 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 either 65 years old and/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 Retired.

I am no longer seeing clients and no longer maintaining my CCC-SLP credentials with ASHA.

I attest that I meet the qualifications for Retired members status.
Signature

Clear
Date

MonthDayYear
Date

Current Specialists can CLICK HERE to log in and pay their application fee ($25 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
Should be Empty: