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Membership Application

Fields marked by * are required.

1. New or Renewal * New Membership     Membership Renewal 2. Name * 3. Degree * 4. Place of Employment 5. License(s) * 6. Office Address * 7. Select One Geographic Area * Allen   Arlington   Carrollton   Denton   Downtown Dallas   Duncanville/Desoto   Farmers Branch   Fort Worth   Garland   HEB   Irving   Lakewood   Lewisville   Mesquite   McKinney   N. Richland Hills   N. Dallas   Oaklawn   Plano   Richardson   Rockwall   S. Dallas   Other     8. Office Phone * 9. Office Fax 10. Email * 11. Website 12. Home Address 13. Home Phone 14. Home Fax 15. Type of Membership * LMFT  $40 Non-LMFT  $40 Retired  $20 Student  $20 Intern  $30 Pac Donation  (optional/any amount) CEU only fee  $10 per session 16. If you are unable to receive the DAMFT Newsletter by email, how would you like to receive it? Fax Newsletter to Mail Newsletter to After submitting this application, remember to MAIL the appropriate dues to: Gloria Martin, MA, LPC, LMFT 10000 North Central Expressway, Suite 400 Dallas, TX 75231