Membership Form

Please enroll me as a member of The New York State Council on Divorce Mediation for the current membership year.

Please Note: You can either choose the option to pay-online (using secure Google checkout) or mail a check for membership renewal.

Select Membership Status:
--==--==--==--==--==--==--==--==--==--==--
New Membership Renewal Membership
(*new members get a one-time discount, membership is $100.00)
--==--==--==--==--==--==--==--==--==--==--

Select Listing Option:
--==--==--==--==--==--==--==--==--==--==--
Option A (Free): Directory Information With E-Mail Address (Listing Only, Not An Active Link)
Option B ($25/Year): Same as option 'A' plus Active E-Mail Link
Option C ($50/Year): Same as option 'B' plus Active Web Site Link (include your URL)
--==--==--==--==--==--==--==--==--==--==--

Total Due:

Please complete the field below:
I, , agree to comply with the Model Standards of Practice of ACR.

Full Name

Primary Address

Street 1

Street 2

City, State, Zip

County

Telephone / Contact Information
Office Number:			Fax Number:
(Optional) Home Number:			Email Address:

Additional Directory Address

Street 1

Street 2

City, State, Zip

County

Additional Office Contact Information
Office Number:			Fax Number:

Degrees currently listed after your name (e.g., J.D., M.S.W.)

Would you prefer to receive correspondence by: U.S. Mail Email?

I will be paying for my membership via: Online Using Secure Google Checkout Mail A Check

*there is an additional 3% fee for using Secure Google Checkout.