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Please complete the following form online and use the PRINT button on your browser to print the completed form. Return the completed form and your check (payable to MSCSW) to: MSCSW, P.O. Box 80594, Minneapolis, MN 55408 |
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Dues: |
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| General Membership LICSW (includes subscription for Clinical Social Work Journal if dues paid before April 1) |
$145.00 |
| Associate Membership LISW, LGSW |
$80.00 |
| Friends of the Society Other mental health professionals |
$80.00 |
| Student Membership Graduate School of Social Work |
$35.00 |
| Emeritus Retired from Practice |
No Dues |
| Clinical Social Work Journal Available Jan 1 to May 1 |
$40.00 |
*New members joining after June 30th pay ½ of dues amount shown above. |
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Application: |
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| Name: | ||
| Renewal?: |
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| Home Address: | ||
| City, State, Zip: | ||
| Home Phone: | ||
| Work Phone: | ||
| E-Mail Address: | ||
| Fax Number: | ||
| Practice Setting: | ||
| Practice Address: | ||
| Position/Title: | ||
PROFESSIONAL EDUCATION |
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| School Attended: | Degree Obtained: | Year: | ||||||||||||||||||
| School Attended: | Degree Obtained: | Year: | ||||||||||||||||||
| License: |
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DUES |
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| Annual Dues: | ||
| Clinical Social Work Journal: | ||
| Total Enclosed: | ||
| Check Number: | ||