ACTA Membership Application
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To become an ACTA member, please print this page; mail or fax the completed form along with your dues to the ACT Association as indicated on the form. Your paid membership will allow you to register for the conference at reduced rates, and provide support for the association to carry forth it's mission of promoting quality ACT services. Thank you.

ACTA
Assertive Community Treatment Association, Inc.
P.O. Box 2428
Brighton, Michigan 48116
P: (810) 227-1859
F: (415) 382-0664
acta@actassociation.org

Name______________________________________________________________________
Title_______________________________________________________________________
Organization_________________________________________________________________
Address____________________________________________________________________
City______________________________________________________________________
State______________________________________________________________________
Zip_______________________________________________________________________
Phone_____________________________________________________________________
Fax_______________________________________________________________________
Email______________________________________________________________________

Annual Membership Fee: Individual Members $35.00 Non-Profit Agency $150.00 For-Profit Agency $375.00

Make Checks Payable To: The ACT Association P.O. Box 2428 Brighton, MI 48116

Mastercard#___________________________________________________________
VISA#_________________________________________________________________
American Express#_____________________________________________________
Discover#_____________________________________________________________

Expiration Date:_________________________________
Signature:______________________________________

New Member________________________________________
Renew Membership________________________________

JOIN THE ACT ASSOCIATION OR RENEW YOUR MEMBERSHIP TODAY AND SAVE ON CONFERENCE REGISTRATION FEES