First name ________________________________

Address ____________________________Apt. _____

City _____________________ State _____ Zip ______

Membership # (required) _________________________

Day Phone (_____) ______ -_________

Certified members joining between October 2004 and December 2004 submit $25.00, as per welcome letter, plus $10.00 for each certification, $35.00 for two, etc.

These fees should be accompanied by a copy of a valid 2005 card and either a copy of your AAHS CEU acceptance notice, ASPT CEU test acceptance notice, or a copy of an ASPT sponsored CEU day certificate of attendance.

All other certified members with a 2005 validation seal currently on their certificate submit $20.00 plus $10.00 for each additional certification, $30.00 for two, etc.

Former members without a 2005 validation seal, between 2000 and 2004, desiring a 2006 validation seal must use Option #1. All others must retake the complete exam.

I am enclosing $_________ for _____ certifications.
Check # _________ M/O # _________________
This form is unconditionally required of all members.
CEU's must be current, submitted and approved for 2006 at least two weeks prior to submitting this form. CEU's should be submitted between November 15, 2005 and November 30, 2005.
This form should be submitted between December 15, 2005 and December 31, 2005.

Send application fees to: