ACMHA Scholarship Application

American College of Mental Health Administration Dues Waiver Form

Complete your information by typing directly onto your browser screen. Place the cursor where you see the brackets, e.g. [Name], highlight the word, and then replace with your own information. Print the form when you are finished then FAX to 505-822-5068 or mail to ACMHA, 7804 Loma del Norte Rd NE, Albuquerque, NM 81709-5419.

Year Requested: [Year]

Name: [Name]

Address: [Address]

City: [City]

State: [State]

Zip Code: [Name]
Zip Code

Work Phone: [Work Phone]

Home Phone: [Home Phone]

Fax: [Fax]

E-Mail Address: [Email]

Current Membership: Yes No

ACMHA Participation: Describe your participation in the Santa Fe Summit, committees, or other ACMHA-related initiatives and activities:
[Describe activities here.]

Special Circumstances Requiring Dues Waiver:

[Explain why you need financial assistance.]

Year Requested:	[Year]
Name:	[Name]
Address:	[Address]
City:	[City]
State:	[State]
Zip Code:	[Name] Zip Code
Work Phone:	[Work Phone]
Home Phone:	[Home Phone]
Fax:	[Fax]
E-Mail Address:	[Email]
Current Membership:	Yes No
ACMHA Participation:	Describe your participation in the Santa Fe Summit, committees, or other ACMHA-related initiatives and activities: [Describe activities here.]
Special Circumstances Requiring Dues Waiver:
	[Explain why you need financial assistance.]