MEMBER INFORMATION
Name __________________________________________________
Mailing Address __________________________________________
City ___________________________ State ______ Zip __________
Home Phone _________________ Work Phone _________________
Preferred Phone: _____ Home _____ Work
Fax ________________ Email ______________________________
Degree ______ Date _______ Specialty ______________________
□Professional/Associate, $72.00 □Student/Retired, $35.00
□ Organizational, for more than one member (call for details)
□WSCA Special (2 yr), $134.00 (reg)/$60.00 (stu/ret)
(95% of dues is deductible)
STUDENT VERIFICATION
College or University _______________________________________
Professor's Signature ______________________________________
NOTE NEW DIVISION: Washington Counselors for Social Justice (WCSJ)
BASIC MEMBERSHIP
___WCA+WASERVIC ___WCA+WAMCD ___WCA+Mental Health ___WCA+WCSJ ___WCA+WSCA ___WCA+WCDA ___WCA+WAAOC ___WCA+WSACES
Additional divisions ($10 each)
___WASERVIC ___WAMCD ___Mental Health ___WCSJ ___WSCA ___WCDA ___WAAOC ___WSACES
___ Send membership directory (electronic download)
___ Payment enclosed (check or money order, payable to WCA in US funds)
___Payment in full ___Installment Option
1st check, $24 ($45 2-yr) + additional divisions
2nd & 3rd checks postdated, $24 ($45 2-yr) each, consecutive months
Charge my ___VISA ___MC ($3 surcharge for card processing)
Card # ______________________ __________ Exp__________
___Installment option (3 monthly payments of $25 ($46 2-yr)
Additional divisions will be charged in full first month
Signature _______________________________________________
Name on Card ___________________________________________
Return to:
Pam Van Der Does, WCA Membership Services
7631 W. Idaho St., Rathdrum ID 83858
Questions? Call 208.755.6121