Application Form
AFCC 2006 New Jersey Chapter Dues

(Please Print This Form to Apply for Membership in NJ-AFCC and AFCC)

New Jersey Chapter Individual Dues:   $30.00 (    )
**Chapter members must be members of the parent AFCC organization.**
AFCC Individual Year:   $150.00  (    )    Institutional Year: $330.00  (     )
Student Year $55.00  (     )   (Student Identification is Required)
Gift Membership $130.00 (    )
Total: $_____________  (    ) Payment Enclosed (U.S. Funds Only: Payable to AFCC)
Charge: (    ) VISA    (    ) MASTERCARD  (Sorry, no American Express)

Credit Card No. ______________________________________ Exp. Date: ________

Signature: ____________________________________________

PROFESSIONAL DESIGNATION

(    ) Attorney
(    ) Academic
(    ) Court Administrator
(    ) Custody Evaluator
(    ) Judicial Officer

(Please check all that apply):

(    ) Mediator
(    ) Mental Health Professional
(    ) Parent Educator
(    ) Researcher
(    ) Other: ____________________________

Name:  ______________________________________________ Degree: _________

Organization: __________________________________________________________

Street Address: ________________________________________________________

City, State/Province: ____________________________ Zip/Postal Code: __________

Country: ______________________________

E-Mail: ________________________________

Phone: _______________________________ Fax: ___________________________

Return Application To: (You may fax applications with credit card payment)

Association of Family and Conciliation Courts
6525 Grand Teton Plaza
Madison, WI  53719-1085
Phone: 608-664-3750    Fax: 608-664-3751
www.afccnet.org
E-mail:  afcc@afccnet.org

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