American College of Mental Health Administration

Membership Application

For questions or concerns about completing this application or any portion of it, please contact ACMHA Executive Director, Kris Ericson, PhD, at 505-822-5038 or Executive.Director@acmha.org for assistance from Kris or an ACMHA Membership Committee member.

Fill in your information by typing directly onto your browser screen: place the cursor where you see the brackets, e.g. [Name]. Highlight the text between the brackets and replace it with your information. Print the form when you are done filling out all the information.

  1. Personal Information

Full Name
[Name]
Home Address
[Address]
(Address cont.)
[Address continued]
City
[City]
State/Province
[State]
Zip/Postal Code
[ZIP]
Country
[Country]
Home Phone
[Home Phone]
FAX
[Home FAX]
E-mail
[Home Email]
  Send College Materials to Home Address

Note: The majority of our communication is now done electronically. Please be sure to provide either a business or personal eMail address.
  1. Professional Information
Position Title
[Title}
Organization
[Organization]
Business Address
[Business Address]
(Address cont.)
{Address continued]
City
[City]
State/Province
[State]
Zip/Postal Code
[ZIP]
Country
[Country]
Work Phone
{Work Phone]
FAX
{Work FAX]
E-mail
[Business Email]
URL
[Organization URL]
Send College Materials to Business Address
     

  1. Professional Credentials/Interests

Please provide a vitae or resume to describe your professional experience and interests, or use an additional sheet for this purpose. This section should address the following:

  • Prior Positions (Include dates and relevance to Mental Health Administration)
  • Other Positions (i.e., not related directly to Mental Health Administration)
  • Major Educational Credentials (include all graduate level studies and degrees)
  • Honors and/or professional recognition

  1. Interest/Involvement in the Field

Please provide a description of your interest, commitment, or contribution to the core issues of mental heath, substance abuse, consumer leadership, or administration. Areas of expertise and special interest may also be noted.

[Enter information here]

 

  1. Additional Information

How did you learn about the college? If you learned of ACMHA from a current member, please state the member's name.

[Enter information here]

 

Why are you interested in membership?

[Enter information here]

 

Which of the ACMHA Initiatives or Activities interest you?

[Enter information here]

 

Please provide the name and contact information for a reference who can offer information on your interests and accomplishments.

[Enter information here]

Please check here if you would like to talk to an ACMHA member to get additional information about being a member of ACMHA.

A completed application requires the following:

  • Completed Application Form (either online or printed),
  • A current resume or vitae, which can easily be included in the online application) or Supplemental Sheet for Items III and IV on the application, and
  • Check or credit card information for first year's dues of $250. Dues payment may be made online with the submission of the application. The link to the eCommerce site is located on the application page.
Membership Process:
  • Completed applications are reviewed by the ACMHA Membership Committee during monthly meetings.
  • The Membership Committee makes recommendations to the ACMHA Board of Directors on candidates for membership.
  • The Board of Directors votes on membership acceptance to the College.
  • The ACMHA office notifies candidates of the decision, providing information about web site resources and access to the Members Only portion of the site.
Dues:
  • Invoice and payment for the first year of dues in the amount of $250 must accompany the application.
  • Applicants not accepted for membership will be refunded their payment in its entirety.
  • Annual dues are currently assessed at $250 on January 1 of each year.
Financial Assistance: The College maintains a small fund to assist applicants in need to support membership dues. Applicants who need assistance should complete a Dues Waiver Application, available at www.acmha.org.

RETURN MATERIALS TO:
A C M H A
7804 Loma del Norte Rd NE
Albuquerque, NM 87109-5419

 
ACMHA

I-N-V-O-I-C-E
I. AMOUNT FOR MEMBERSHIP DUES: $250.00
II. SUBSCRIPTION TO Mental Health Weekly:
     SUBSCRIPTION TO Alcohol & Drug Abuse Weekly:		 $299.00 (optional)
$299.00 (optional)

III. CONTRIBUTIONS TO SUPPORT ACMHA

The American College of Mental Health Administration appreciates your support of its important activities and initiatives. Please consider making a tax-deductible contribution.

ACMHA Contribution(s)
     1. Leadership Institute Fund
$_____ (amount)
     2. Summit and Initiatives
$_____ (amount)
     3. ACMHA Consumer Fund
$_____ (amount)
     4. General Fund
$_____ (amount)
         TOTAL
$_____ (total amount)
 
TOTAL AMOUNT REMITTED:
$_____
Card No. __________________________________________
Name on Card ______________________________________
Expiration Date _________________Zip Code ___________
Signature __________________________________________
[ ]
MasterCard
[ ]
Visa
OR make a check payable to ACMHA and mail to:
    ACMHA
    c/o Kris Ericson, Executive Director
    7804 Loma del Norte Rd NE
    Albuquerque, NM 87109-5419