First Name:

Middle Name:

Last Name:

Degree/Title:

Street Address:

City:

State/Province:

Zip Code:

Country:

Place of Work:

Position:

Home Phone:

Work Phone:

Email:

Fax Number:

Church Affiliation:

Field of Service:

Education and Training Relevant to Pastoral Care:

I certify that the information in my application is accurate and true to the best of my knowledge. I am actively involve in providing pastoral care and upholding Christian principles and I am willing to abide by the Standards and Code of Ethics of the IACC. Please accept my application for Active Membership. I am mailing you a check or money order in the amount of US$75. Thank you.

Please, I Would like to receive the application packet for Board Certification:
Yes
No