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Membership Application  You Must hold a Christian Counseling Certificate from a recognized organization in addition to a degree. Do not complete this application if you have applied for the ICCA Certificate Program 2718 West Walnut St., Rogers, Arkansas 72756    501- 636-7497   800-494-7497  http://www.freedombiblecollege.org/icc.html Please type or print.  It is important to complete all information. PART I: Personal   1. Last Name ______________________First Name ______________________Middle _____________ 2. Address __________________________________________________ P.O. Box ________________ 3. City_________________________State________(Country)_______________Postal Code ________ 4. Home phone _________________ Office ________________ E-Mail _________________________ 5. Date of Birth (mm/dd/yy)  ______ /_____ /_____     SSN/SIN ______-______-______  Sex ______ 6. Church membership:_________________________________________________________________   PART II: Christian Counseling Certificate Information   1. Issuing Organization ________________________________________________________________ 2. Contact Person ___________________________________________ Phone ___________________ 3. Expiration Date of Certificate ______________________   PART III: Education   College Attended  Location  Dates  Degree 1. . . . 2. . . . 3.  . . .  PART IV: Membership Fees (check one)    1. ___ I have enclosed $75 for the first year. 2. ___ I wish to apply for a lifetime membership and I enclose $400.00.  We take Visa, Master Card, Discover, Check, Money Order  (Will not be processed without the proper fees) PART V: Credentials   1. Credentials currently held:  Ministerial License ____    Ordination ____    Other _____    None _____   (Define if Other ____________________________________________________________________) 2. With what organization? _____________________________________________________________ 3. Do you plan to apply for credentials with Concepts of Freedom Ministries?    Yes____    No  ____    (For details on CFM credentials, please go to the web page <http://www.freedombiblecollege.org/ordination.html> or contact the office.) 4. Do you plan to apply for membership with Freedom Christian Ministries Association? Yes___  No__  5. If yes, will the application be for your  counseling practice _____     church _____     both _____    (For details on FCMA membership, please go to the web page <http://www.freedombiblecollege.org/affiliate.html>    or contact the office.) Part VI: Signature This application must be completed and signed before it will be processed.  If you have questions about the application process, please call or email.  ______________________________________________                                 __________________ Signature of applicant                                                                                   Date signed     Please help us serve better: 1.  How did you hear about the International Christian Counselors Alliance ?_______________________ 2.  Why did you choose ICCA?______________________________________ 3.  Suggestions or comments: ___________________________________________________________ ___________________________________________________________________________________   ICCA Use Only Approved:    Yes                  No                      Yes with conditions  ____________________________________________________________________________________   CFM-ICCA Form 201                                                                           ©2000 - 2009 Concepts of Freedom Ministries, Inc.