| |
| |
|
|
| Salutation: |
|
| First
Name: |
|
| Middle: |
|
| Last
Name: |
|
| Suffix: |
e.g.
Jr., III, PhD., LCSW, MD, (Ret), etc. |
|
|
| Please
complete this section ONLY if your information has changed. |
|
|
| Title
|
|
| Organization
|
|
| Address: |
|
| City: |
|
| State: |
|
| Zip
Code: |
|
| County: |
|
| Business
Phone: |
|
| Fax
#: |
|
| Email: |
|
| Website
address: |
|
|
|
| MEMBERSHIP
INFORMATION: |
|
|
|
TAM
lists member addresses, telephone and e-mail on the
website. |
|
I do NOT
want to be listed on the website |
|
ANNUAL
DUES (TAM membership dues apply to the calendar
year in which you are joining. However, if you are renewing
after October 1st, dues will be applied to the following
calendar year. Please check one.) |
|
Full Member - $75
Candidate for Membership* - $45
Friend of TAM - $50 (Note: Friends of TAM do not have
to complete the following section.) |
|
|
|
CONTINUING EDUCATION |
|
|
|
To
maintain membership, members must participate in a minimum
of twelve (12) hours of mediation or mediation related
continuing education each year, of which at least three
(3) hours must be related to ethics. This continuing
education requirement may be partially satisfied by
up to two (2) hours of self-study as defined by paragraph
4.8.2.0 of the TAM bylaws. |
|
Candidates
for Membership and Full Members:
By
signing below, I certifiy that I have completed a
minimum of twelve (12) hours of mediation or mediation
related continuing education in the last year, of
which at least threee (3) hours were related to ethics. |
|
|
|
|
| Date: |
|
| Signature: |
|
|
|
|
Prior
Candidates for Membership applying for Full Membership:
By
signing below, I certify that I have obtained the
training, education, professional and/or mediation
experience to renew at the Full Member level. |
| Date: |
|
| Signature: |
|
|
|
| *Candidate
status may be maintained for a maximum of five (5) year
in order to allow the Candidate time to complete the
100 hours of experience or other membership requirements. |
| |
When
finished, please click the "Submit" button.
|